Rep. Barbara Flynn Currie

Filed: 5/18/2016

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 420

2    AMENDMENT NO. ______. Amend Senate Bill 420 by replacing
3everything after the enacting clause with the following:
 
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,

 

 

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1or elsewhere; (6) medical care, or any other type of remedial
2care furnished by licensed practitioners; (7) home health care
3services; (8) private duty nursing service; (9) clinic
4services; (10) dental services, including prevention and
5treatment of periodontal disease and dental caries disease for
6pregnant women, provided by an individual licensed to practice
7dentistry or dental surgery; for purposes of this item (10),
8"dental services" means diagnostic, preventive, or corrective
9procedures provided by or under the supervision of a dentist in
10the practice of his or her profession; (11) physical therapy
11and related services; (12) prescribed drugs, dentures, and
12prosthetic devices; and eyeglasses prescribed by a physician
13skilled in the diseases of the eye, or by an optometrist,
14whichever the person may select; (13) other diagnostic,
15screening, preventive, and rehabilitative services, including
16to ensure that the individual's need for intervention or
17treatment of mental disorders or substance use disorders or
18co-occurring mental health and substance use disorders is
19determined using a uniform screening, assessment, and
20evaluation process inclusive of criteria, for children and
21adults; for purposes of this item (13), a uniform screening,
22assessment, and evaluation process refers to a process that
23includes an appropriate evaluation and, as warranted, a
24referral; "uniform" does not mean the use of a singular
25instrument, tool, or process that all must utilize; (14)
26transportation and such other expenses as may be necessary;

 

 

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1(15) medical treatment of sexual assault survivors, as defined
2in Section 1a of the Sexual Assault Survivors Emergency
3Treatment Act, for injuries sustained as a result of the sexual
4assault, including examinations and laboratory tests to
5discover evidence which may be used in criminal proceedings
6arising from the sexual assault; (16) the diagnosis and
7treatment of sickle cell anemia; and (17) any other medical
8care, and any other type of remedial care recognized under the
9laws of this State, but not including abortions, or induced
10miscarriages or premature births, unless, in the opinion of a
11physician, such procedures are necessary for the preservation
12of the life of the woman seeking such treatment, or except an
13induced premature birth intended to produce a live viable child
14and such procedure is necessary for the health of the mother or
15her unborn child. The Illinois Department, by rule, shall
16prohibit any physician from providing medical assistance to
17anyone eligible therefor under this Code where such physician
18has been found guilty of performing an abortion procedure in a
19wilful and wanton manner upon a woman who was not pregnant at
20the time such abortion procedure was performed. The term "any
21other type of remedial care" shall include nursing care and
22nursing home service for persons who rely on treatment by
23spiritual means alone through prayer for healing.
24    Notwithstanding any other provision of this Section, a
25comprehensive tobacco use cessation program that includes
26purchasing prescription drugs or prescription medical devices

 

 

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

 

 

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

 

 

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1this provision.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in accordance
4with the classes of persons designated in Section 5-2.
5    The Department of Healthcare and Family Services must
6provide coverage and reimbursement for amino acid-based
7elemental formulas, regardless of delivery method, for the
8diagnosis and treatment of (i) eosinophilic disorders and (ii)
9short bowel syndrome when the prescribing physician has issued
10a written order stating that the amino acid-based elemental
11formula is medically necessary.
12    The Illinois Department shall authorize the provision of,
13and shall authorize payment for, screening by low-dose
14mammography for the presence of occult breast cancer for women
1535 years of age or older who are eligible for medical
16assistance under this Article, as follows:
17        (A) A baseline mammogram for women 35 to 39 years of
18    age.
19        (B) An annual mammogram for women 40 years of age or
20    older.
21        (C) A mammogram at the age and intervals considered
22    medically necessary by the woman's health care provider for
23    women under 40 years of age and having a family history of
24    breast cancer, prior personal history of breast cancer,
25    positive genetic testing, or other risk factors.
26        (D) A comprehensive ultrasound screening of an entire

 

 

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1    breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue, when medically
3    necessary as determined by a physician licensed to practice
4    medicine in all of its branches.
5        (E) A screening MRI when medically necessary, as
6    determined by a physician licensed to practice medicine in
7    all of its branches.
8    All screenings shall include a physical breast exam,
9instruction on self-examination and information regarding the
10frequency of self-examination and its value as a preventative
11tool. For purposes of this Section, "low-dose mammography"
12means the x-ray examination of the breast using equipment
13dedicated specifically for mammography, including the x-ray
14tube, filter, compression device, and image receptor, with an
15average radiation exposure delivery of less than one rad per
16breast for 2 views of an average size breast. The term also
17includes digital mammography.
18    On and after January 1, 2016, the Department shall ensure
19that all networks of care for adult clients of the Department
20include access to at least one breast imaging Center of Imaging
21Excellence as certified by the American College of Radiology.
22    On and after January 1, 2012, providers participating in a
23quality improvement program approved by the Department shall be
24reimbursed for screening and diagnostic mammography at the same
25rate as the Medicare program's rates, including the increased
26reimbursement for digital mammography.

 

 

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

 

 

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1months, of the importance and benefit of screening mammography.
2The Department shall work with experts in breast cancer
3outreach and patient navigation to optimize these reminders and
4shall establish a methodology for evaluating their
5effectiveness and modifying the methodology based on the
6evaluation.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. On or after July 1,
202016, the pilot program shall be expanded to include one site
21in western Illinois, one site in southern Illinois, one site in
22central Illinois, and 4 sites within metropolitan Chicago. An
23evaluation of the pilot program shall be carried out measuring
24health outcomes and cost of care for those served by the pilot
25program compared to similarly situated patients who are not
26served by the pilot program.

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1is being made are actually being received by eligible
2recipients. Within 90 days after September 16, 1984 (the
3effective date of Public Act 83-1439) this amendatory Act of
41984, the Illinois Department shall establish a current list of
5acquisition costs for all prosthetic devices and any other
6items recognized as medical equipment and supplies
7reimbursable under this Article and shall update such list on a
8quarterly basis, except that the acquisition costs of all
9prescription drugs shall be updated no less frequently than
10every 30 days as required by Section 5-5.12.
11    The rules and regulations of the Illinois Department shall
12require that a written statement including the required opinion
13of a physician shall accompany any claim for reimbursement for
14abortions, or induced miscarriages or premature births. This
15statement shall indicate what procedures were used in providing
16such medical services.
17    Notwithstanding any other law to the contrary, the Illinois
18Department shall, within 365 days after July 22, 2013 (the
19effective date of Public Act 98-104), establish procedures to
20permit skilled care facilities licensed under the Nursing Home
21Care Act to submit monthly billing claims for reimbursement
22purposes. Following development of these procedures, the
23Department shall, by July 1, 2016, test the viability of the
24new system and implement any necessary operational or
25structural changes to its information technology platforms in
26order to allow for the direct acceptance and payment of nursing

 

 

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1home claims.
2    Notwithstanding any other law to the contrary, the Illinois
3Department shall, within 365 days after August 15, 2014 (the
4effective date of Public Act 98-963), establish procedures to
5permit ID/DD facilities licensed under the ID/DD Community Care
6Act and MC/DD facilities licensed under the MC/DD Act to submit
7monthly billing claims for reimbursement purposes. Following
8development of these procedures, the Department shall have an
9additional 365 days to test the viability of the new system and
10to ensure that any necessary operational or structural changes
11to its information technology 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

 

 

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1inquiries could indicate potential existence of claims or liens
2for the Illinois Department.
3    Enrollment of a vendor shall be subject to a provisional
4period and shall be conditional for one year. During the period
5of conditional enrollment, the Department may terminate the
6vendor's eligibility to participate in, or may disenroll the
7vendor 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.

 

 

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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

 

 

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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 5 days of
16receipt by the facility of required prescreening information,
17data for new admissions shall be entered into the Medical
18Electronic Data Interchange (MEDI) or the Recipient
19Eligibility Verification (REV) System or successor system, and
20within 15 days of receipt by the facility of required
21prescreening information, admission documents shall be
22submitted through MEDI or REV or shall be submitted directly to
23the Department of Human Services using required admission
24forms. Effective September 1, 2014, admission documents,
25including all prescreening information, must be submitted
26through MEDI or REV. Confirmation numbers assigned to an

 

 

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

 

 

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

 

 

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1take any action or acquire any products or services.
2    The Illinois Department shall establish policies,
3procedures, standards and criteria by rule for the acquisition,
4repair and replacement of orthotic and prosthetic devices and
5durable medical equipment. Such rules shall provide, but not be
6limited to, the following services: (1) immediate repair or
7replacement of such devices by recipients; and (2) rental,
8lease, purchase or lease-purchase of durable medical equipment
9in a cost-effective manner, taking into consideration the
10recipient's medical prognosis, the extent of the recipient's
11needs, and the requirements and costs for maintaining such
12equipment. Subject to prior approval, such rules shall enable a
13recipient to temporarily acquire and use alternative or
14substitute devices or equipment pending repairs or
15replacements of any device or equipment previously authorized
16for such recipient by the Department. Notwithstanding any
17provision of Section 5-5f to the contrary, the Department may,
18by rule, exempt certain replacement wheelchair parts from prior
19approval and determine the wholesale price by methods other
20than actual acquisition costs.
21    The Department shall require, by rule, all providers of
22durable medical equipment to be accredited by an accreditation
23organization approved by the federal Centers for Medicare and
24Medicaid Services and recognized by the Department in order to
25bill the Department for providing durable medical equipment to
26recipients. No later than 15 months after the effective date of

 

 

09900SB0420ham001- 23 -LRB099 03252 KTG 48631 a

1the rule adopted pursuant to this paragraph, all providers must
2meet the accreditation requirement.
3    The Department shall execute, relative to the nursing home
4prescreening project, written inter-agency agreements with the
5Department of Human Services and the Department on Aging, to
6effect the following: (i) intake procedures and common
7eligibility criteria for those persons who are receiving
8non-institutional services; and (ii) the establishment and
9development of non-institutional services in areas of the State
10where they are not currently available or are undeveloped; and
11(iii) notwithstanding any other provision of law, subject to
12federal approval, on and after July 1, 2012, an increase in the
13determination of need (DON) scores from 29 to 37 for applicants
14for institutional and home and community-based long term care;
15if and only if federal approval is not granted, the Department
16may, in conjunction with other affected agencies, implement
17utilization controls or changes in benefit packages to
18effectuate a similar savings amount for this population; and
19(iv) no later than July 1, 2013, minimum level of care
20eligibility criteria for institutional and home and
21community-based long term care; and (v) no later than October
221, 2013, establish procedures to permit long term care
23providers access to eligibility scores for individuals with an
24admission date who are seeking or receiving services from the
25long term care provider. In order to select the minimum level
26of care eligibility criteria, the Governor shall establish a

 

 

09900SB0420ham001- 24 -LRB099 03252 KTG 48631 a

1workgroup that includes affected agency representatives and
2stakeholders representing the institutional and home and
3community-based long term care interests. This Section shall
4not restrict the Department from implementing lower level of
5care eligibility criteria for community-based services in
6circumstances where federal approval has been granted.
7    The Illinois Department shall develop and operate, in
8cooperation with other State Departments and agencies and in
9compliance with applicable federal laws and regulations,
10appropriate and effective systems of health care evaluation and
11programs for monitoring of utilization of health care services
12and facilities, as it affects persons eligible for medical
13assistance under this Code.
14    The Illinois Department shall report annually to the
15General Assembly, no later than the second Friday in April of
161979 and each year thereafter, in regard to:
17        (a) actual statistics and trends in utilization of
18    medical services by public aid recipients;
19        (b) actual statistics and trends in the provision of
20    the various medical services by medical vendors;
21        (c) current rate structures and proposed changes in
22    those rate structures for the various medical vendors; and
23        (d) efforts at utilization review and control by the
24    Illinois Department.
25    The period covered by each report shall be the 3 years
26ending on the June 30 prior to the report. The report shall

 

 

09900SB0420ham001- 25 -LRB099 03252 KTG 48631 a

1include suggested legislation for consideration by the General
2Assembly. The filing of one copy of the report with the
3Speaker, one copy with the Minority Leader and one copy with
4the Clerk of the House of Representatives, one copy with the
5President, one copy with the Minority Leader and one copy with
6the Secretary of the Senate, one copy with the Legislative
7Research Unit, and such additional copies with the State
8Government Report Distribution Center for the General Assembly
9as is required under paragraph (t) of Section 7 of the State
10Library Act shall be deemed sufficient to comply with this
11Section.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18    On and after July 1, 2012, the Department shall reduce any
19rate of reimbursement for services or other payments or alter
20any methodologies authorized by this Code to reduce any rate of
21reimbursement for services or other payments in accordance with
22Section 5-5e.
23    Because kidney transplantation can be an appropriate, cost
24effective alternative to renal dialysis when medically
25necessary and notwithstanding the provisions of Section 1-11 of
26this Code, beginning October 1, 2014, the Department shall

 

 

09900SB0420ham001- 26 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 27 -LRB099 03252 KTG 48631 a

1to the dispensing and administration of the opioid antagonist,
2shall be covered under the medical assistance program for
3persons who are otherwise eligible for medical assistance under
4this Article. As used in this Section, "opioid antagonist"
5means a drug that binds to opioid receptors and blocks or
6inhibits the effect of opioids acting on those receptors,
7including, but not limited to, naloxone hydrochloride or any
8other similarly acting drug approved by the U.S. Food and Drug
9Administration.
10(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1198-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
128-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
13eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1499-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
158-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
16    (Text of Section after amendment by P.A. 99-407)
17    Sec. 5-5. Medical services. The Illinois Department, by
18rule, shall determine the quantity and quality of and the rate
19of reimbursement for the medical assistance for which payment
20will be authorized, and the medical services to be provided,
21which may include all or part of the following: (1) inpatient
22hospital services; (2) outpatient hospital services; (3) other
23laboratory and X-ray services; (4) skilled nursing home
24services; (5) physicians' services whether furnished in the
25office, the patient's home, a hospital, a skilled nursing home,

 

 

09900SB0420ham001- 28 -LRB099 03252 KTG 48631 a

1or elsewhere; (6) medical care, or any other type of remedial
2care furnished by licensed practitioners; (7) home health care
3services; (8) private duty nursing service; (9) clinic
4services; (10) dental services, including prevention and
5treatment of periodontal disease and dental caries disease for
6pregnant women, provided by an individual licensed to practice
7dentistry or dental surgery; for purposes of this item (10),
8"dental services" means diagnostic, preventive, or corrective
9procedures provided by or under the supervision of a dentist in
10the practice of his or her profession; (11) physical therapy
11and related services; (12) prescribed drugs, dentures, and
12prosthetic devices; and eyeglasses prescribed by a physician
13skilled in the diseases of the eye, or by an optometrist,
14whichever the person may select; (13) other diagnostic,
15screening, preventive, and rehabilitative services, including
16to ensure that the individual's need for intervention or
17treatment of mental disorders or substance use disorders or
18co-occurring mental health and substance use disorders is
19determined using a uniform screening, assessment, and
20evaluation process inclusive of criteria, for children and
21adults; for purposes of this item (13), a uniform screening,
22assessment, and evaluation process refers to a process that
23includes an appropriate evaluation and, as warranted, a
24referral; "uniform" does not mean the use of a singular
25instrument, tool, or process that all must utilize; (14)
26transportation and such other expenses as may be necessary;

 

 

09900SB0420ham001- 29 -LRB099 03252 KTG 48631 a

1(15) medical treatment of sexual assault survivors, as defined
2in Section 1a of the Sexual Assault Survivors Emergency
3Treatment Act, for injuries sustained as a result of the sexual
4assault, including examinations and laboratory tests to
5discover evidence which may be used in criminal proceedings
6arising from the sexual assault; (16) the diagnosis and
7treatment of sickle cell anemia; and (17) any other medical
8care, and any other type of remedial care recognized under the
9laws of this State, but not including abortions, or induced
10miscarriages or premature births, unless, in the opinion of a
11physician, such procedures are necessary for the preservation
12of the life of the woman seeking such treatment, or except an
13induced premature birth intended to produce a live viable child
14and such procedure is necessary for the health of the mother or
15her unborn child. The Illinois Department, by rule, shall
16prohibit any physician from providing medical assistance to
17anyone eligible therefor under this Code where such physician
18has been found guilty of performing an abortion procedure in a
19wilful and wanton manner upon a woman who was not pregnant at
20the time such abortion procedure was performed. The term "any
21other type of remedial care" shall include nursing care and
22nursing home service for persons who rely on treatment by
23spiritual means alone through prayer for healing.
24    Notwithstanding any other provision of this Section, a
25comprehensive tobacco use cessation program that includes
26purchasing prescription drugs or prescription medical devices

 

 

09900SB0420ham001- 30 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 31 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 32 -LRB099 03252 KTG 48631 a

1this provision.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in accordance
4with the classes of persons designated in Section 5-2.
5    The Department of Healthcare and Family Services must
6provide coverage and reimbursement for amino acid-based
7elemental formulas, regardless of delivery method, for the
8diagnosis and treatment of (i) eosinophilic disorders and (ii)
9short bowel syndrome when the prescribing physician has issued
10a written order stating that the amino acid-based elemental
11formula is medically necessary.
12    The Illinois Department shall authorize the provision of,
13and shall authorize payment for, screening by low-dose
14mammography for the presence of occult breast cancer for women
1535 years of age or older who are eligible for medical
16assistance under this Article, as follows:
17        (A) A baseline mammogram for women 35 to 39 years of
18    age.
19        (B) An annual mammogram for women 40 years of age or
20    older.
21        (C) A mammogram at the age and intervals considered
22    medically necessary by the woman's health care provider for
23    women under 40 years of age and having a family history of
24    breast cancer, prior personal history of breast cancer,
25    positive genetic testing, or other risk factors.
26        (D) A comprehensive ultrasound screening of an entire

 

 

09900SB0420ham001- 33 -LRB099 03252 KTG 48631 a

1    breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue, when medically
3    necessary as determined by a physician licensed to practice
4    medicine in all of its branches.
5        (E) A screening MRI when medically necessary, as
6    determined by a physician licensed to practice medicine in
7    all of its branches.
8    All screenings shall include a physical breast exam,
9instruction on self-examination and information regarding the
10frequency of self-examination and its value as a preventative
11tool. For purposes of this Section, "low-dose mammography"
12means the x-ray examination of the breast using equipment
13dedicated specifically for mammography, including the x-ray
14tube, filter, compression device, and image receptor, with an
15average radiation exposure delivery of less than one rad per
16breast for 2 views of an average size breast. The term also
17includes digital mammography and includes breast
18tomosynthesis. As used in this Section, the term "breast
19tomosynthesis" means a radiologic procedure that involves the
20acquisition of projection images over the stationary breast to
21produce cross-sectional digital three-dimensional images of
22the breast.
23    On and after January 1, 2016, the Department shall ensure
24that all networks of care for adult clients of the Department
25include access to at least one breast imaging Center of Imaging
26Excellence as certified by the American College of Radiology.

 

 

09900SB0420ham001- 34 -LRB099 03252 KTG 48631 a

1    On and after January 1, 2012, providers participating in a
2quality improvement program approved by the Department shall be
3reimbursed for screening and diagnostic mammography at the same
4rate as the Medicare program's rates, including the increased
5reimbursement for digital mammography.
6    The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10    On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16    The Department shall convene an expert panel, including
17representatives of hospitals, free standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the

 

 

09900SB0420ham001- 35 -LRB099 03252 KTG 48631 a

1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7The Department shall work with experts in breast cancer
8outreach and patient navigation to optimize these reminders and
9shall establish a methodology for evaluating their
10effectiveness and modifying the methodology based on the
11evaluation.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. On or after July 1,
252016, the pilot program shall be expanded to include one site
26in western Illinois, one site in southern Illinois, one site in

 

 

09900SB0420ham001- 36 -LRB099 03252 KTG 48631 a

1central Illinois, and 4 sites within metropolitan Chicago. An
2evaluation of the pilot program shall be carried out measuring
3health outcomes and cost of care for those served by the pilot
4program compared to similarly situated patients who are not
5served by the pilot program.
6    The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include access
11for patients diagnosed with cancer to at least one academic
12commission on cancer-accredited cancer program as an
13in-network covered benefit.
14    Any medical or health care provider shall immediately
15recommend, to any pregnant woman who is being provided prenatal
16services and is suspected of drug abuse or is addicted as
17defined in the Alcoholism and Other Drug Abuse and Dependency
18Act, referral to a local substance abuse treatment provider
19licensed by the Department of Human Services or to a licensed
20hospital which provides substance abuse treatment services.
21The Department of Healthcare and Family Services shall assure
22coverage for the cost of treatment of the drug abuse or
23addiction for pregnant recipients in accordance with the
24Illinois Medicaid Program in conjunction with the Department of
25Human Services.
26    All medical providers providing medical assistance to

 

 

09900SB0420ham001- 37 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 38 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 39 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 40 -LRB099 03252 KTG 48631 a

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

 

 

09900SB0420ham001- 41 -LRB099 03252 KTG 48631 a

1proof of receipt, unless the Illinois Department shall have put
2into effect and shall be operating a system of post-payment
3audit and review which shall, on a sampling basis, be deemed
4adequate by the Illinois Department to assure that such drugs,
5dentures, prosthetic devices and eyeglasses for which payment
6is being made are actually being received by eligible
7recipients. Within 90 days after September 16, 1984 (the
8effective date of Public Act 83-1439) this amendatory Act of
91984, the Illinois Department shall establish a current list of
10acquisition costs for all prosthetic devices and any other
11items recognized as medical equipment and supplies
12reimbursable under this Article and shall update such list on a
13quarterly basis, except that the acquisition costs of all
14prescription drugs shall be updated no less frequently than
15every 30 days as required by Section 5-5.12.
16    The rules and regulations of the Illinois Department shall
17require that a written statement including the required opinion
18of a physician shall accompany any claim for reimbursement for
19abortions, or induced miscarriages or premature births. This
20statement shall indicate what procedures were used in providing
21such medical services.
22    Notwithstanding any other law to the contrary, the Illinois
23Department shall, within 365 days after July 22, 2013 (the
24effective date of Public Act 98-104), establish procedures to
25permit skilled care facilities licensed under the Nursing Home
26Care Act to submit monthly billing claims for reimbursement

 

 

09900SB0420ham001- 42 -LRB099 03252 KTG 48631 a

1purposes. Following development of these procedures, the
2Department shall, by July 1, 2016, test the viability of the
3new system and implement any necessary operational or
4structural changes to its information technology platforms in
5order to allow for the direct acceptance and payment of nursing
6home claims.
7    Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after August 15, 2014 (the
9effective date of Public Act 98-963), establish procedures to
10permit ID/DD facilities licensed under the ID/DD Community Care
11Act and MC/DD facilities licensed under the MC/DD Act to submit
12monthly billing claims for reimbursement purposes. Following
13development of these procedures, the Department shall have an
14additional 365 days to test the viability of the new system and
15to ensure that any necessary operational or structural changes
16to its information technology platforms are implemented.
17    The Illinois Department shall require all dispensers of
18medical services, other than an individual practitioner or
19group of practitioners, desiring to participate in the Medical
20Assistance program established under this Article to disclose
21all financial, beneficial, ownership, equity, surety or other
22interests in any and all firms, corporations, partnerships,
23associations, business enterprises, joint ventures, agencies,
24institutions or other legal entities providing any form of
25health care services in this State under this Article.
26    The Illinois Department may require that all dispensers of

 

 

09900SB0420ham001- 43 -LRB099 03252 KTG 48631 a

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1durable medical equipment to be accredited by an accreditation
2organization approved by the federal Centers for Medicare and
3Medicaid Services and recognized by the Department in order to
4bill the Department for providing durable medical equipment to
5recipients. No later than 15 months after the effective date of
6the rule adopted pursuant to this paragraph, all providers must
7meet the accreditation requirement.
8    The Department shall execute, relative to the nursing home
9prescreening project, written inter-agency agreements with the
10Department of Human Services and the Department on Aging, to
11effect the following: (i) intake procedures and common
12eligibility criteria for those persons who are receiving
13non-institutional services; and (ii) the establishment and
14development of non-institutional services in areas of the State
15where they are not currently available or are undeveloped; and
16(iii) notwithstanding any other provision of law, subject to
17federal approval, on and after July 1, 2012, an increase in the
18determination of need (DON) scores from 29 to 37 for applicants
19for institutional and home and community-based long term care;
20if and only if federal approval is not granted, the Department
21may, in conjunction with other affected agencies, implement
22utilization controls or changes in benefit packages to
23effectuate a similar savings amount for this population; and
24(iv) no later than July 1, 2013, minimum level of care
25eligibility criteria for institutional and home and
26community-based long term care; and (v) no later than October

 

 

09900SB0420ham001- 50 -LRB099 03252 KTG 48631 a

11, 2013, establish procedures to permit long term care
2providers access to eligibility scores for individuals with an
3admission date who are seeking or receiving services from the
4long term care provider. In order to select the minimum level
5of care eligibility criteria, the Governor shall establish a
6workgroup that includes affected agency representatives and
7stakeholders representing the institutional and home and
8community-based long term care interests. This Section shall
9not restrict the Department from implementing lower level of
10care eligibility criteria for community-based services in
11circumstances where federal approval 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 and
16programs for monitoring of utilization of health care services
17and facilities, as it affects persons eligible for medical
18assistance 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

 

 

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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 filing of one copy of the report with the
8Speaker, one copy with the Minority Leader and one copy with
9the Clerk of the House of Representatives, one copy with the
10President, one copy with the Minority Leader and one copy with
11the Secretary of the Senate, one copy with the Legislative
12Research Unit, and such additional copies with the State
13Government Report Distribution Center for the General Assembly
14as is required under paragraph (t) of Section 7 of the State
15Library Act shall be deemed sufficient to comply with this
16Section.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23    On and after July 1, 2012, the Department shall reduce any
24rate of reimbursement for services or other payments or alter
25any methodologies authorized by this Code to reduce any rate of
26reimbursement for services or other payments in accordance with

 

 

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

 

 

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1placement criteria, (2) prior authorization mandate, or (3)
2lifetime restriction limit mandate.
3    On or after July 1, 2015, opioid antagonists prescribed for
4the treatment of an opioid overdose, including the medication
5product, administration devices, and any pharmacy fees related
6to the dispensing and administration of the opioid antagonist,
7shall be covered under the medical assistance program for
8persons who are otherwise eligible for medical assistance under
9this Article. As used in this Section, "opioid antagonist"
10means a drug that binds to opioid receptors and blocks or
11inhibits the effect of opioids acting on those receptors,
12including, but not limited to, naloxone hydrochloride or any
13other similarly acting drug approved by the U.S. Food and Drug
14Administration.
15(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1698-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
178-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
18eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1999-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2099 of P.A. 99-407 for its effective date); 99-433, eff.
218-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
22    Section 95. No acceleration or delay. Where this Act makes
23changes in a statute that is represented in this Act by text
24that is not yet or no longer in effect (for example, a Section
25represented by multiple versions), the use of that text does

 

 

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1not accelerate or delay the taking effect of (i) the changes
2made by this Act or (ii) provisions derived from any other
3Public Act.".