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

 

 

09900SB0420ham003- 23 -LRB099 03252 KTG 49033 a

1bill the Department for providing durable medical equipment to
2recipients. No later than 15 months after the effective date of
3the rule adopted pursuant to this paragraph, all providers must
4meet the accreditation requirement.
5    The Department shall execute, relative to the nursing home
6prescreening project, written inter-agency agreements with the
7Department of Human Services and the Department on Aging, to
8effect the following: (i) intake procedures and common
9eligibility criteria for those persons who are receiving
10non-institutional services; and (ii) the establishment and
11development of non-institutional services in areas of the State
12where they are not currently available or are undeveloped; and
13(iii) notwithstanding any other provision of law, subject to
14federal approval, on and after July 1, 2012, an increase in the
15determination of need (DON) scores from 29 to 37 for applicants
16for institutional and home and community-based long term care;
17if and only if federal approval is not granted, the Department
18may, in conjunction with other affected agencies, implement
19utilization controls or changes in benefit packages to
20effectuate a similar savings amount for this population; and
21(iv) no later than July 1, 2013, minimum level of care
22eligibility criteria for institutional and home and
23community-based long term care; and (v) no later than October
241, 2013, establish procedures to permit long term care
25providers access to eligibility scores for individuals with an
26admission date who are seeking or receiving services from the

 

 

09900SB0420ham003- 24 -LRB099 03252 KTG 49033 a

1long term care provider. In order to select the minimum level
2of care eligibility criteria, the Governor shall establish a
3workgroup that includes affected agency representatives and
4stakeholders representing the institutional and home and
5community-based long term care interests. This Section shall
6not restrict the Department from implementing lower level of
7care eligibility criteria for community-based services in
8circumstances where federal approval has been granted.
9    The Illinois Department shall develop and operate, in
10cooperation with other State Departments and agencies and in
11compliance with applicable federal laws and regulations,
12appropriate and effective systems of health care evaluation and
13programs for monitoring of utilization of health care services
14and facilities, as it affects persons eligible for medical
15assistance under this Code.
16    The Illinois Department shall report annually to the
17General Assembly, no later than the second Friday in April of
181979 and each year thereafter, in regard to:
19        (a) actual statistics and trends in utilization of
20    medical services by public aid recipients;
21        (b) actual statistics and trends in the provision of
22    the various medical services by medical vendors;
23        (c) current rate structures and proposed changes in
24    those rate structures for the various medical vendors; and
25        (d) efforts at utilization review and control by the
26    Illinois Department.

 

 

09900SB0420ham003- 25 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 26 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 27 -LRB099 03252 KTG 49033 a

1the treatment of an opioid overdose, including the medication
2product, administration devices, and any pharmacy fees related
3to the dispensing and administration of the opioid antagonist,
4shall be covered under the medical assistance program for
5persons who are otherwise eligible for medical assistance under
6this Article. As used in this Section, "opioid antagonist"
7means a drug that binds to opioid receptors and blocks or
8inhibits the effect of opioids acting on those receptors,
9including, but not limited to, naloxone hydrochloride or any
10other similarly acting drug approved by the U.S. Food and Drug
11Administration.
12(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1398-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
148-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
15eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1699-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
178-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
18    (Text of Section after amendment by P.A. 99-407)
19    Sec. 5-5. Medical services. The Illinois Department, by
20rule, shall determine the quantity and quality of and the rate
21of reimbursement for the medical assistance for which payment
22will be authorized, and the medical services to be provided,
23which may include all or part of the following: (1) inpatient
24hospital services; (2) outpatient hospital services; (3) other
25laboratory and X-ray services; (4) skilled nursing home

 

 

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

 

 

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

 

 

09900SB0420ham003- 30 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 31 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 32 -LRB099 03252 KTG 49033 a

1The Department shall establish a process for payment of claims
2for reimbursement for covered dental services rendered under
3this provision.
4    The Illinois Department, by rule, may distinguish and
5classify the medical services to be provided only in accordance
6with the classes of persons designated in Section 5-2.
7    The Department of Healthcare and Family Services must
8provide coverage and reimbursement for amino acid-based
9elemental formulas, regardless of delivery method, for the
10diagnosis and treatment of (i) eosinophilic disorders and (ii)
11short bowel syndrome when the prescribing physician has issued
12a written order stating that the amino acid-based elemental
13formula is medically necessary.
14    The Illinois Department shall authorize the provision of,
15and shall authorize payment for, screening by low-dose
16mammography for the presence of occult breast cancer for women
1735 years of age or older who are eligible for medical
18assistance under this Article, as follows:
19        (A) A baseline mammogram for women 35 to 39 years of
20    age.
21        (B) An annual mammogram for women 40 years of age or
22    older.
23        (C) A mammogram at the age and intervals considered
24    medically necessary by the woman's health care provider for
25    women under 40 years of age and having a family history of
26    breast cancer, prior personal history of breast cancer,

 

 

09900SB0420ham003- 33 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 34 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 35 -LRB099 03252 KTG 49033 a

1These clinics or centers may also collaborate with other
2hospital-based mammography facilities. By January 1, 2016, the
3Department shall report to the General Assembly on the status
4of the provision set forth in this paragraph.
5    The Department shall establish a methodology to remind
6women who are age-appropriate for screening mammography, but
7who have not received a mammogram within the previous 18
8months, of the importance and benefit of screening mammography.
9The Department shall work with experts in breast cancer
10outreach and patient navigation to optimize these reminders and
11shall establish a methodology for evaluating their
12effectiveness and modifying the methodology based on the
13evaluation.
14    The Department shall establish a performance goal for
15primary care providers with respect to their female patients
16over age 40 receiving an annual mammogram. This performance
17goal shall be used to provide additional reimbursement in the
18form of a quality performance bonus to primary care providers
19who meet that goal.
20    The Department shall devise a means of case-managing or
21patient navigation for beneficiaries diagnosed with breast
22cancer. This program shall initially operate as a pilot program
23in areas of the State with the highest incidence of mortality
24related to breast cancer. At least one pilot program site shall
25be in the metropolitan Chicago area and at least one site shall
26be outside the metropolitan Chicago area. On or after July 1,

 

 

09900SB0420ham003- 36 -LRB099 03252 KTG 49033 a

12016, the pilot program shall be expanded to include one site
2in western Illinois, one site in southern Illinois, one site in
3central Illinois, and 4 sites within metropolitan Chicago. An
4evaluation of the pilot program shall be carried out measuring
5health outcomes and cost of care for those served by the pilot
6program compared to similarly situated patients who are not
7served by the pilot program.
8    The Department shall require all networks of care to
9develop a means either internally or by contract with experts
10in navigation and community outreach to navigate cancer
11patients to comprehensive care in a timely fashion. The
12Department shall require all networks of care to include access
13for patients diagnosed with cancer to at least one academic
14commission on cancer-accredited cancer program as an
15in-network covered benefit.
16    Any medical or health care provider shall immediately
17recommend, to any pregnant woman who is being provided prenatal
18services and is suspected of drug abuse or is addicted as
19defined in the Alcoholism and Other Drug Abuse and Dependency
20Act, referral to a local substance abuse treatment provider
21licensed by the Department of Human Services or to a licensed
22hospital which provides substance abuse treatment services.
23The Department of Healthcare and Family Services shall assure
24coverage for the cost of treatment of the drug abuse or
25addiction for pregnant recipients in accordance with the
26Illinois Medicaid Program in conjunction with the Department of

 

 

09900SB0420ham003- 37 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 38 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 39 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 40 -LRB099 03252 KTG 49033 a

1    The Department shall apply for a waiver from the United
2States Health Care Financing Administration to allow for the
3implementation of Partnerships under this Section.
4    The Illinois Department shall require health care
5providers to maintain records that document the medical care
6and services provided to recipients of Medical Assistance under
7this Article. Such records must be retained for a period of not
8less than 6 years from the date of service or as provided by
9applicable State law, whichever period is longer, except that
10if an audit is initiated within the required retention period
11then the records must be retained until the audit is completed
12and every exception is resolved. The Illinois Department shall
13require health care providers to make available, when
14authorized by the patient, in writing, the medical records in a
15timely fashion to other health care providers who are treating
16or serving persons eligible for Medical Assistance under this
17Article. All dispensers of medical services shall be required
18to maintain and retain business and professional records
19sufficient to fully and accurately document the nature, scope,
20details and receipt of the health care provided to persons
21eligible for medical assistance under this Code, in accordance
22with regulations promulgated by the Illinois Department. The
23rules and regulations shall require that proof of the receipt
24of prescription drugs, dentures, prosthetic devices and
25eyeglasses by eligible persons under this Section accompany
26each claim for reimbursement submitted by the dispenser of such

 

 

09900SB0420ham003- 41 -LRB099 03252 KTG 49033 a

1medical services. No such claims for reimbursement shall be
2approved for payment by the Illinois Department without such
3proof of receipt, unless the Illinois Department shall have put
4into effect and shall be operating a system of post-payment
5audit and review which shall, on a sampling basis, be deemed
6adequate by the Illinois Department to assure that such drugs,
7dentures, prosthetic devices and eyeglasses for which payment
8is being made are actually being received by eligible
9recipients. Within 90 days after September 16, 1984 (the
10effective date of Public Act 83-1439) this amendatory Act of
111984, the Illinois Department shall establish a current list of
12acquisition costs for all prosthetic devices and any other
13items recognized as medical equipment and supplies
14reimbursable under this Article and shall update such list on a
15quarterly basis, except that the acquisition costs of all
16prescription drugs shall be updated no less frequently than
17every 30 days as required by Section 5-5.12.
18    The rules and regulations of the Illinois Department shall
19require that a written statement including the required opinion
20of a physician shall accompany any claim for reimbursement for
21abortions, or induced miscarriages or premature births. This
22statement shall indicate what procedures were used in providing
23such medical services.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, within 365 days after July 22, 2013 (the
26effective date of Public Act 98-104), establish procedures to

 

 

09900SB0420ham003- 42 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 43 -LRB099 03252 KTG 49033 a

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

09900SB0420ham003- 49 -LRB099 03252 KTG 49033 a

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

 

 

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1effectuate a similar savings amount for this population; and
2(iv) no later than July 1, 2013, minimum level of care
3eligibility criteria for institutional and home and
4community-based long term care; and (v) no later than October
51, 2013, establish procedures to permit long term care
6providers access to eligibility scores for individuals with an
7admission date who are seeking or receiving services from the
8long term care provider. In order to select the minimum level
9of care eligibility criteria, the Governor shall establish a
10workgroup that includes affected agency representatives and
11stakeholders representing the institutional and home and
12community-based long term care interests. This Section shall
13not restrict the Department from implementing lower level of
14care eligibility criteria for community-based services in
15circumstances where federal approval has been granted.
16    The Illinois Department shall develop and operate, in
17cooperation with other State Departments and agencies and in
18compliance with applicable federal laws and regulations,
19appropriate and effective systems of health care evaluation and
20programs for monitoring of utilization of health care services
21and facilities, as it affects persons eligible for medical
22assistance under this Code.
23    The Illinois Department shall report annually to the
24General Assembly, no later than the second Friday in April of
251979 and each year thereafter, in regard to:
26        (a) actual statistics and trends in utilization of

 

 

09900SB0420ham003- 51 -LRB099 03252 KTG 49033 a

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

 

 

09900SB0420ham003- 52 -LRB099 03252 KTG 49033 a

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

 

 

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1assistance programs for persons who are otherwise eligible for
2medical assistance under this Article and shall not be subject
3to any (1) utilization control, other than those established
4under the American Society of Addiction Medicine patient
5placement criteria, (2) prior authorization mandate, or (3)
6lifetime restriction limit mandate.
7    On or after July 1, 2015, opioid antagonists prescribed for
8the treatment of an opioid overdose, including the medication
9product, administration devices, and any pharmacy fees related
10to the dispensing and administration of the opioid antagonist,
11shall be covered under the medical assistance program for
12persons who are otherwise eligible for medical assistance under
13this Article. As used in this Section, "opioid antagonist"
14means a drug that binds to opioid receptors and blocks or
15inhibits the effect of opioids acting on those receptors,
16including, but not limited to, naloxone hydrochloride or any
17other similarly acting drug approved by the U.S. Food and Drug
18Administration.
19(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2098-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
218-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
22eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2399-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2499 of P.A. 99-407 for its effective date); 99-433, eff.
258-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 

 

 

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1    Section 95. No acceleration or delay. Where this Act makes
2changes in a statute that is represented in this Act by text
3that is not yet or no longer in effect (for example, a Section
4represented by multiple versions), the use of that text does
5not accelerate or delay the taking effect of (i) the changes
6made by this Act or (ii) provisions derived from any other
7Public Act.".