Rep. Barbara Flynn Currie

Filed: 5/20/2016

 

 


 

 


 
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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, for wheelchairs and wheelchair parts only,
20determine the wholesale price by methods other than actual
21acquisition costs.
22    The Department shall require, by rule, all providers of
23durable medical equipment to be accredited by an accreditation
24organization approved by the federal Centers for Medicare and
25Medicaid Services and recognized by the Department in order to
26bill the Department for providing durable medical equipment to

 

 

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1recipients. No later than 15 months after the effective date of
2the rule adopted pursuant to this paragraph, all providers must
3meet the accreditation requirement.
4    The Department shall execute, relative to the nursing home
5prescreening project, written inter-agency agreements with the
6Department of Human Services and the Department on Aging, to
7effect the following: (i) intake procedures and common
8eligibility criteria for those persons who are receiving
9non-institutional services; and (ii) the establishment and
10development of non-institutional services in areas of the State
11where they are not currently available or are undeveloped; and
12(iii) notwithstanding any other provision of law, subject to
13federal approval, on and after July 1, 2012, an increase in the
14determination of need (DON) scores from 29 to 37 for applicants
15for institutional and home and community-based long term care;
16if and only if federal approval is not granted, the Department
17may, in conjunction with other affected agencies, implement
18utilization controls or changes in benefit packages to
19effectuate a similar savings amount for this population; and
20(iv) no later than July 1, 2013, minimum level of care
21eligibility criteria for institutional and home and
22community-based long term care; and (v) no later than October
231, 2013, establish procedures to permit long term care
24providers access to eligibility scores for individuals with an
25admission date who are seeking or receiving services from the
26long term care provider. In order to select the minimum level

 

 

09900SB0420ham002- 24 -LRB099 03252 KTG 48996 a

1of care eligibility criteria, the Governor shall establish a
2workgroup that includes affected agency representatives and
3stakeholders representing the institutional and home and
4community-based long term care interests. This Section shall
5not restrict the Department from implementing lower level of
6care eligibility criteria for community-based services in
7circumstances where federal approval has been granted.
8    The Illinois Department shall develop and operate, in
9cooperation with other State Departments and agencies and in
10compliance with applicable federal laws and regulations,
11appropriate and effective systems of health care evaluation and
12programs for monitoring of utilization of health care services
13and facilities, as it affects persons eligible for medical
14assistance under this Code.
15    The Illinois Department shall report annually to the
16General Assembly, no later than the second Friday in April of
171979 and each year thereafter, in regard to:
18        (a) actual statistics and trends in utilization of
19    medical services by public aid recipients;
20        (b) actual statistics and trends in the provision of
21    the various medical services by medical vendors;
22        (c) current rate structures and proposed changes in
23    those rate structures for the various medical vendors; and
24        (d) efforts at utilization review and control by the
25    Illinois Department.
26    The period covered by each report shall be the 3 years

 

 

09900SB0420ham002- 25 -LRB099 03252 KTG 48996 a

1ending on the June 30 prior to the report. The report shall
2include suggested legislation for consideration by the General
3Assembly. The filing of one copy of the report with the
4Speaker, one copy with the Minority Leader and one copy with
5the Clerk of the House of Representatives, one copy with the
6President, one copy with the Minority Leader and one copy with
7the Secretary of the Senate, one copy with the Legislative
8Research Unit, and such additional copies with the State
9Government Report Distribution Center for the General Assembly
10as is required under paragraph (t) of Section 7 of the State
11Library Act shall be deemed sufficient to comply with this
12Section.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate of
22reimbursement for services or other payments in accordance with
23Section 5-5e.
24    Because kidney transplantation can be an appropriate, cost
25effective alternative to renal dialysis when medically
26necessary and notwithstanding the provisions of Section 1-11 of

 

 

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

 

 

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1product, administration devices, and any pharmacy fees related
2to the dispensing and administration of the opioid antagonist,
3shall be covered under the medical assistance program for
4persons who are otherwise eligible for medical assistance under
5this Article. As used in this Section, "opioid antagonist"
6means a drug that binds to opioid receptors and blocks or
7inhibits the effect of opioids acting on those receptors,
8including, but not limited to, naloxone hydrochloride or any
9other similarly acting drug approved by the U.S. Food and Drug
10Administration.
11(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1298-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
138-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
14eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1599-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
168-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
17    (Text of Section after amendment by P.A. 99-407)
18    Sec. 5-5. Medical services. The Illinois Department, by
19rule, shall determine the quantity and quality of and the rate
20of reimbursement for the medical assistance for which payment
21will be authorized, and the medical services to be provided,
22which may include all or part of the following: (1) inpatient
23hospital services; (2) outpatient hospital services; (3) other
24laboratory and X-ray services; (4) skilled nursing home
25services; (5) physicians' services whether furnished in the

 

 

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

 

 

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

 

 

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

 

 

09900SB0420ham002- 31 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 32 -LRB099 03252 KTG 48996 a

1for reimbursement for covered dental services rendered under
2this provision.
3    The Illinois Department, by rule, may distinguish and
4classify the medical services to be provided only in accordance
5with the classes of persons designated in Section 5-2.
6    The Department of Healthcare and Family Services must
7provide coverage and reimbursement for amino acid-based
8elemental formulas, regardless of delivery method, for the
9diagnosis and treatment of (i) eosinophilic disorders and (ii)
10short bowel syndrome when the prescribing physician has issued
11a written order stating that the amino acid-based elemental
12formula is medically necessary.
13    The Illinois Department shall authorize the provision of,
14and shall authorize payment for, screening by low-dose
15mammography for the presence of occult breast cancer for women
1635 years of age or older who are eligible for medical
17assistance under this Article, as follows:
18        (A) A baseline mammogram for women 35 to 39 years of
19    age.
20        (B) An annual mammogram for women 40 years of age or
21    older.
22        (C) A mammogram at the age and intervals considered
23    medically necessary by the woman's health care provider for
24    women under 40 years of age and having a family history of
25    breast cancer, prior personal history of breast cancer,
26    positive genetic testing, or other risk factors.

 

 

09900SB0420ham002- 33 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 34 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 35 -LRB099 03252 KTG 48996 a

1hospital-based mammography facilities. By January 1, 2016, the
2Department shall report to the General Assembly on the status
3of the provision set forth in this paragraph.
4    The Department shall establish a methodology to remind
5women who are age-appropriate for screening mammography, but
6who have not received a mammogram within the previous 18
7months, of the importance and benefit of screening mammography.
8The Department shall work with experts in breast cancer
9outreach and patient navigation to optimize these reminders and
10shall establish a methodology for evaluating their
11effectiveness and modifying the methodology based on the
12evaluation.
13    The Department shall establish a performance goal for
14primary care providers with respect to their female patients
15over age 40 receiving an annual mammogram. This performance
16goal shall be used to provide additional reimbursement in the
17form of a quality performance bonus to primary care providers
18who meet that goal.
19    The Department shall devise a means of case-managing or
20patient navigation for beneficiaries diagnosed with breast
21cancer. This program shall initially operate as a pilot program
22in areas of the State with the highest incidence of mortality
23related to breast cancer. At least one pilot program site shall
24be in the metropolitan Chicago area and at least one site shall
25be outside the metropolitan Chicago area. On or after July 1,
262016, the pilot program shall be expanded to include one site

 

 

09900SB0420ham002- 36 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 37 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 38 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 39 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 40 -LRB099 03252 KTG 48996 a

1States Health Care Financing Administration to allow for the
2implementation of Partnerships under this Section.
3    The Illinois Department shall require health care
4providers to maintain records that document the medical care
5and services provided to recipients of Medical Assistance under
6this Article. Such records must be retained for a period of not
7less than 6 years from the date of service or as provided by
8applicable State law, whichever period is longer, except that
9if an audit is initiated within the required retention period
10then the records must be retained until the audit is completed
11and every exception is resolved. The Illinois Department shall
12require health care providers to make available, when
13authorized by the patient, in writing, the medical records in a
14timely fashion to other health care providers who are treating
15or serving persons eligible for Medical Assistance under this
16Article. All dispensers of medical services shall be required
17to maintain and retain business and professional records
18sufficient to fully and accurately document the nature, scope,
19details and receipt of the health care provided to persons
20eligible for medical assistance under this Code, in accordance
21with regulations promulgated by the Illinois Department. The
22rules and regulations shall require that proof of the receipt
23of prescription drugs, dentures, prosthetic devices and
24eyeglasses by eligible persons under this Section accompany
25each claim for reimbursement submitted by the dispenser of such
26medical services. No such claims for reimbursement shall be

 

 

09900SB0420ham002- 41 -LRB099 03252 KTG 48996 a

1approved for payment by the Illinois Department without such
2proof of receipt, unless the Illinois Department shall have put
3into effect and shall be operating a system of post-payment
4audit and review which shall, on a sampling basis, be deemed
5adequate by the Illinois Department to assure that such drugs,
6dentures, prosthetic devices and eyeglasses for which payment
7is being made are actually being received by eligible
8recipients. Within 90 days after September 16, 1984 (the
9effective date of Public Act 83-1439) this amendatory Act of
101984, the Illinois Department shall establish a current list of
11acquisition costs for all prosthetic devices and any other
12items recognized as medical equipment and supplies
13reimbursable under this Article and shall update such list on a
14quarterly basis, except that the acquisition costs of all
15prescription drugs shall be updated no less frequently than
16every 30 days as required by Section 5-5.12.
17    The rules and regulations of the Illinois Department shall
18require that a written statement including the required opinion
19of a physician shall accompany any claim for reimbursement for
20abortions, or induced miscarriages or premature births. This
21statement shall indicate what procedures were used in providing
22such medical services.
23    Notwithstanding any other law to the contrary, the Illinois
24Department shall, within 365 days after July 22, 2013 (the
25effective date of Public Act 98-104), establish procedures to
26permit skilled care facilities licensed under the Nursing Home

 

 

09900SB0420ham002- 42 -LRB099 03252 KTG 48996 a

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

 

 

09900SB0420ham002- 43 -LRB099 03252 KTG 48996 a

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1acquisition costs.
2    The Department shall require, by rule, all providers of
3durable medical equipment to be accredited by an accreditation
4organization approved by the federal Centers for Medicare and
5Medicaid Services and recognized by the Department in order to
6bill the Department for providing durable medical equipment to
7recipients. No later than 15 months after the effective date of
8the rule adopted pursuant to this paragraph, all providers must
9meet the accreditation requirement.
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(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1898-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
198-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
20eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2199-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2299 of P.A. 99-407 for its effective date); 99-433, eff.
238-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
24    Section 95. No acceleration or delay. Where this Act makes
25changes in a statute that is represented in this Act by text

 

 

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1that is not yet or no longer in effect (for example, a Section
2represented by multiple versions), the use of that text does
3not accelerate or delay the taking effect of (i) the changes
4made by this Act or (ii) provisions derived from any other
5Public Act.".