Illinois General Assembly - Full Text of HB4408
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Full Text of HB4408  102nd General Assembly

HB4408enr 102ND GENERAL ASSEMBLY

  
  
  

 


 
HB4408 EnrolledLRB102 22908 KTG 32061 b

1    AN ACT concerning health insurance co-pays.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.23 as follows:
 
6    (215 ILCS 5/356z.23)
7    Sec. 356z.23. Coverage for opioid antagonists.
8    (a) An individual or group policy of accident and health
9insurance amended, delivered, issued, or renewed in this State
10after the effective date of this amendatory Act of the 99th
11General Assembly that provides coverage for prescription drugs
12must provide coverage for at least one opioid antagonist,
13including the medication product, administration devices, and
14any pharmacy administration fees related to the dispensing of
15the opioid antagonist. This coverage must include refills for
16expired or utilized opioid antagonists.
17    (a-5) Notwithstanding subsection (a), no individual or
18group policy of accident and health insurance amended,
19delivered, issued, or renewed after January 1, 2024 that
20provides coverage for naloxone hydrochloride shall impose a
21copayment on the coverage provided, except that this
22subsection does not apply to coverage of naloxone
23hydrochloride to the extent such coverage would disqualify a

 

 

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1high-deductible health plan from eligibility for a health
2savings account under Section 223 of the Internal Revenue
3Code.
4    (b) As used in this Section, "opioid antagonist" means a
5drug that binds to opioid receptors and blocks or inhibits the
6effect of opioids acting on those receptors, including, but
7not limited to, naloxone hydrochloride or any other similarly
8acting drug approved by the U.S. Food and Drug Administration.
9(Source: P.A. 99-480, eff. 9-9-15.)
 
10    Section 10. The Illinois Public Aid Code is amended by
11changing Section 5-5 as follows:
 
12    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
13    Sec. 5-5. Medical services. The Illinois Department, by
14rule, shall determine the quantity and quality of and the rate
15of reimbursement for the medical assistance for which payment
16will be authorized, and the medical services to be provided,
17which may include all or part of the following: (1) inpatient
18hospital services; (2) outpatient hospital services; (3) other
19laboratory and X-ray services; (4) skilled nursing home
20services; (5) physicians' services whether furnished in the
21office, the patient's home, a hospital, a skilled nursing
22home, or elsewhere; (6) medical care, or any other type of
23remedial care furnished by licensed practitioners; (7) home
24health care services; (8) private duty nursing service; (9)

 

 

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

 

 

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1sexual assault, including examinations and laboratory tests to
2discover evidence which may be used in criminal proceedings
3arising from the sexual assault; (16) the diagnosis and
4treatment of sickle cell anemia; (16.5) services performed by
5a chiropractic physician licensed under the Medical Practice
6Act of 1987 and acting within the scope of his or her license,
7including, but not limited to, chiropractic manipulative
8treatment; and (17) any other medical care, and any other type
9of remedial care recognized under the laws of this State. The
10term "any other type of remedial care" shall include nursing
11care and nursing home service for persons who rely on
12treatment by spiritual means alone through prayer for healing.
13    Notwithstanding any other provision of this Section, a
14comprehensive tobacco use cessation program that includes
15purchasing prescription drugs or prescription medical devices
16approved by the Food and Drug Administration shall be covered
17under the medical assistance program under this Article for
18persons who are otherwise eligible for assistance under this
19Article.
20    Notwithstanding any other provision of this Code,
21reproductive health care that is otherwise legal in Illinois
22shall be covered under the medical assistance program for
23persons who are otherwise eligible for medical assistance
24under this Article.
25    Notwithstanding any other provision of this Section, all
26tobacco cessation medications approved by the United States

 

 

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1Food and Drug Administration and all individual and group
2tobacco cessation counseling services and telephone-based
3counseling services and tobacco cessation medications provided
4through the Illinois Tobacco Quitline shall be covered under
5the medical assistance program for persons who are otherwise
6eligible for assistance under this Article. The Department
7shall comply with all federal requirements necessary to obtain
8federal financial participation, as specified in 42 CFR
9433.15(b)(7), for telephone-based counseling services provided
10through the Illinois Tobacco Quitline, including, but not
11limited to: (i) entering into a memorandum of understanding or
12interagency agreement with the Department of Public Health, as
13administrator of the Illinois Tobacco Quitline; and (ii)
14developing a cost allocation plan for Medicaid-allowable
15Illinois Tobacco Quitline services in accordance with 45 CFR
1695.507. The Department shall submit the memorandum of
17understanding or interagency agreement, the cost allocation
18plan, and all other necessary documentation to the Centers for
19Medicare and Medicaid Services for review and approval.
20Coverage under this paragraph shall be contingent upon federal
21approval.
22    Notwithstanding any other provision of this Code, the
23Illinois Department may not require, as a condition of payment
24for any laboratory test authorized under this Article, that a
25physician's handwritten signature appear on the laboratory
26test order form. The Illinois Department may, however, impose

 

 

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

 

 

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1        (1) dental services provided by or under the
2    supervision of a dentist; and
3        (2) eyeglasses prescribed by a physician skilled in
4    the diseases of the eye, or by an optometrist, whichever
5    the person may select.
6    On and after July 1, 2018, the Department of Healthcare
7and Family Services shall provide dental services to any adult
8who is otherwise eligible for assistance under the medical
9assistance program. As used in this paragraph, "dental
10services" means diagnostic, preventative, restorative, or
11corrective procedures, including procedures and services for
12the prevention and treatment of periodontal disease and dental
13caries disease, provided by an individual who is licensed to
14practice dentistry or dental surgery or who is under the
15supervision of a dentist in the practice of his or her
16profession.
17    On and after July 1, 2018, targeted dental services, as
18set forth in Exhibit D of the Consent Decree entered by the
19United States District Court for the Northern District of
20Illinois, Eastern Division, in the matter of Memisovski v.
21Maram, Case No. 92 C 1982, that are provided to adults under
22the medical assistance program shall be established at no less
23than the rates set forth in the "New Rate" column in Exhibit D
24of the Consent Decree for targeted dental services that are
25provided to persons under the age of 18 under the medical
26assistance program.

 

 

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1    Notwithstanding any other provision of this Code and
2subject to federal approval, the Department may adopt rules to
3allow a dentist who is volunteering his or her service at no
4cost to render dental services through an enrolled
5not-for-profit health clinic without the dentist personally
6enrolling as a participating provider in the medical
7assistance program. A not-for-profit health clinic shall
8include a public health clinic or Federally Qualified Health
9Center or other enrolled provider, as determined by the
10Department, through which dental services covered under this
11Section are performed. The Department shall establish a
12process for payment of claims for reimbursement for covered
13dental services rendered under this provision.
14    On and after January 1, 2022, the Department of Healthcare
15and Family Services shall administer and regulate a
16school-based dental program that allows for the out-of-office
17delivery of preventative dental services in a school setting
18to children under 19 years of age. The Department shall
19establish, by rule, guidelines for participation by providers
20and set requirements for follow-up referral care based on the
21requirements established in the Dental Office Reference Manual
22published by the Department that establishes the requirements
23for dentists participating in the All Kids Dental School
24Program. Every effort shall be made by the Department when
25developing the program requirements to consider the different
26geographic differences of both urban and rural areas of the

 

 

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1State for initial treatment and necessary follow-up care. No
2provider shall be charged a fee by any unit of local government
3to participate in the school-based dental program administered
4by the Department. Nothing in this paragraph shall be
5construed to limit or preempt a home rule unit's or school
6district's authority to establish, change, or administer a
7school-based dental program in addition to, or independent of,
8the school-based dental program administered by the
9Department.
10    The Illinois Department, by rule, may distinguish and
11classify the medical services to be provided only in
12accordance with the classes of persons designated in Section
135-2.
14    The Department of Healthcare and Family Services must
15provide coverage and reimbursement for amino acid-based
16elemental formulas, regardless of delivery method, for the
17diagnosis and treatment of (i) eosinophilic disorders and (ii)
18short bowel syndrome when the prescribing physician has issued
19a written order stating that the amino acid-based elemental
20formula is medically necessary.
21    The Illinois Department shall authorize the provision of,
22and shall authorize payment for, screening by low-dose
23mammography for the presence of occult breast cancer for
24individuals 35 years of age or older who are eligible for
25medical assistance under this Article, as follows:
26        (A) A baseline mammogram for individuals 35 to 39

 

 

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1    years of age.
2        (B) An annual mammogram for individuals 40 years of
3    age or older.
4        (C) A mammogram at the age and intervals considered
5    medically necessary by the individual's health care
6    provider for individuals under 40 years of age and having
7    a family history of breast cancer, prior personal history
8    of breast cancer, positive genetic testing, or other risk
9    factors.
10        (D) A comprehensive ultrasound screening and MRI of an
11    entire breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue or when medically
13    necessary as determined by a physician licensed to
14    practice medicine in all of its branches.
15        (E) A screening MRI when medically necessary, as
16    determined by a physician licensed to practice medicine in
17    all of its branches.
18        (F) A diagnostic mammogram when medically necessary,
19    as determined by a physician licensed to practice medicine
20    in all its branches, advanced practice registered nurse,
21    or physician assistant.
22    The Department shall not impose a deductible, coinsurance,
23copayment, or any other cost-sharing requirement on the
24coverage provided under this paragraph; except that this
25sentence does not apply to coverage of diagnostic mammograms
26to the extent such coverage would disqualify a high-deductible

 

 

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1health plan from eligibility for a health savings account
2pursuant to Section 223 of the Internal Revenue Code (26
3U.S.C. 223).
4    All screenings shall include a physical breast exam,
5instruction on self-examination and information regarding the
6frequency of self-examination and its value as a preventative
7tool.
8     For purposes of this Section:
9    "Diagnostic mammogram" means a mammogram obtained using
10diagnostic mammography.
11    "Diagnostic mammography" means a method of screening that
12is designed to evaluate an abnormality in a breast, including
13an abnormality seen or suspected on a screening mammogram or a
14subjective or objective abnormality otherwise detected in the
15breast.
16    "Low-dose mammography" means the x-ray examination of the
17breast using equipment dedicated specifically for mammography,
18including the x-ray tube, filter, compression device, and
19image receptor, with an average radiation exposure delivery of
20less than one rad per breast for 2 views of an average size
21breast. The term also includes digital mammography and
22includes breast tomosynthesis.
23    "Breast tomosynthesis" means a radiologic procedure that
24involves the acquisition of projection images over the
25stationary breast to produce cross-sectional digital
26three-dimensional images of the breast.

 

 

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1    If, at any time, the Secretary of the United States
2Department of Health and Human Services, or its successor
3agency, promulgates rules or regulations to be published in
4the Federal Register or publishes a comment in the Federal
5Register or issues an opinion, guidance, or other action that
6would require the State, pursuant to any provision of the
7Patient Protection and Affordable Care Act (Public Law
8111-148), including, but not limited to, 42 U.S.C.
918031(d)(3)(B) or any successor provision, to defray the cost
10of any coverage for breast tomosynthesis outlined in this
11paragraph, then the requirement that an insurer cover breast
12tomosynthesis is inoperative other than any such coverage
13authorized under Section 1902 of the Social Security Act, 42
14U.S.C. 1396a, and the State shall not assume any obligation
15for the cost of coverage for breast tomosynthesis set forth in
16this paragraph.
17    On and after January 1, 2016, the Department shall ensure
18that all networks of care for adult clients of the Department
19include access to at least one breast imaging Center of
20Imaging Excellence as certified by the American College of
21Radiology.
22    On and after January 1, 2012, providers participating in a
23quality improvement program approved by the Department shall
24be reimbursed for screening and diagnostic mammography at the
25same rate as the Medicare program's rates, including the
26increased reimbursement 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
25individuals who are age-appropriate for screening mammography,
26but who have not received a mammogram within the previous 18

 

 

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1months, of the importance and benefit of screening
2mammography. The Department shall work with experts in breast
3cancer outreach and patient navigation to optimize these
4reminders and shall establish a methodology for evaluating
5their effectiveness 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
16program in areas of the State with the highest incidence of
17mortality related to breast cancer. At least one pilot program
18site shall be in the metropolitan Chicago area and at least one
19site shall be outside the metropolitan Chicago area. On or
20after July 1, 2016, the pilot program shall be expanded to
21include one site in western Illinois, one site in southern
22Illinois, one site in central Illinois, and 4 sites within
23metropolitan Chicago. An evaluation of the pilot program shall
24be carried out measuring health outcomes and cost of care for
25those served by the pilot program compared to similarly
26situated patients who are not served 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
6access for patients diagnosed with cancer to at least one
7academic commission on cancer-accredited cancer program as an
8in-network covered benefit.
9    On or after July 1, 2022, individuals who are otherwise
10eligible for medical assistance under this Article shall
11receive coverage for perinatal depression screenings for the
1212-month period beginning on the last day of their pregnancy.
13Medical assistance coverage under this paragraph shall be
14conditioned on the use of a screening instrument approved by
15the Department.
16    Any medical or health care provider shall immediately
17recommend, to any pregnant individual who is being provided
18prenatal services and is suspected of having a substance use
19disorder as defined in the Substance Use Disorder Act,
20referral to a local substance use disorder treatment program
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

 

 

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1of Human Services.
2    All medical providers providing medical assistance to
3pregnant individuals under this Code shall receive information
4from the Department on the availability of services under any
5program providing case management services for addicted
6individuals, including information on appropriate referrals
7for other social services that may be needed by addicted
8individuals in addition to treatment for 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
12a public awareness campaign, may provide information
13concerning treatment for alcoholism and drug abuse and
14addiction, prenatal health care, and other pertinent programs
15directed at reducing the number of drug-affected infants born
16to recipients of medical 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 the recipient's substance
20abuse.
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,

 

 

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

 

 

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

 

 

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

 

 

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1eyeglasses by eligible persons under this Section accompany
2each claim for reimbursement submitted by the dispenser of
3such medical services. No such claims for reimbursement shall
4be approved for payment by the Illinois Department without
5such proof of receipt, unless the Illinois Department shall
6have put into effect and shall be operating a system of
7post-payment audit and review which shall, on a sampling
8basis, be deemed adequate by the Illinois Department to assure
9that such drugs, dentures, prosthetic devices and eyeglasses
10for which payment is being made are actually being received by
11eligible recipients. Within 90 days after September 16, 1984
12(the effective date of Public Act 83-1439), the Illinois
13Department shall establish a current list of acquisition costs
14for all prosthetic devices and any other items recognized as
15medical equipment and supplies reimbursable under this Article
16and shall update such list on a quarterly basis, except that
17the acquisition costs of all prescription drugs shall be
18updated no less frequently than every 30 days as required by
19Section 5-5.12.
20    Notwithstanding any other law to the contrary, the
21Illinois Department shall, within 365 days after July 22, 2013
22(the effective date of Public Act 98-104), establish
23procedures to permit skilled care facilities licensed under
24the Nursing Home Care Act to submit monthly billing claims for
25reimbursement purposes. Following development of these
26procedures, the Department shall, by July 1, 2016, test the

 

 

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1viability of the new system and implement any necessary
2operational or structural changes to its information
3technology platforms in order to allow for the direct
4acceptance and payment of nursing home claims.
5    Notwithstanding any other law to the contrary, the
6Illinois Department shall, within 365 days after August 15,
72014 (the effective date of Public Act 98-963), establish
8procedures to permit ID/DD facilities licensed under the ID/DD
9Community Care Act and MC/DD facilities licensed under the
10MC/DD Act to submit monthly billing claims for reimbursement
11purposes. Following development of these procedures, the
12Department shall have an additional 365 days to test the
13viability of the new system and to ensure that any necessary
14operational or structural changes to its information
15technology platforms are implemented.
16    The Illinois Department shall require all dispensers of
17medical services, other than an individual practitioner or
18group of practitioners, desiring to participate in the Medical
19Assistance program established under this Article to disclose
20all financial, beneficial, ownership, equity, surety or other
21interests in any and all firms, corporations, partnerships,
22associations, business enterprises, joint ventures, agencies,
23institutions or other legal entities providing any form of
24health care services in this State under this Article.
25    The Illinois Department may require that all dispensers of
26medical services desiring to participate in the medical

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1durable medical equipment to be accredited by an accreditation
2organization approved by the federal Centers for Medicare and
3Medicaid Services and recognized by the Department in order to
4bill the Department for providing durable medical equipment to
5recipients. No later than 15 months after the effective date
6of the rule adopted pursuant to this paragraph, all providers
7must meet the accreditation requirement.
8    In order to promote environmental responsibility, meet the
9needs of recipients and enrollees, and achieve significant
10cost savings, the Department, or a managed care organization
11under contract with the Department, may provide recipients or
12managed care enrollees who have a prescription or Certificate
13of Medical Necessity access to refurbished durable medical
14equipment under this Section (excluding prosthetic and
15orthotic devices as defined in the Orthotics, Prosthetics, and
16Pedorthics Practice Act and complex rehabilitation technology
17products and associated services) through the State's
18assistive technology program's reutilization program, using
19staff with the Assistive Technology Professional (ATP)
20Certification if the refurbished durable medical equipment:
21(i) is available; (ii) is less expensive, including shipping
22costs, than new durable medical equipment of the same type;
23(iii) is able to withstand at least 3 years of use; (iv) is
24cleaned, disinfected, sterilized, and safe in accordance with
25federal Food and Drug Administration regulations and guidance
26governing the reprocessing of medical devices in health care

 

 

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1settings; and (v) equally meets the needs of the recipient or
2enrollee. The reutilization program shall confirm that the
3recipient or enrollee is not already in receipt of the same or
4similar equipment from another service provider, and that the
5refurbished durable medical equipment equally meets the needs
6of the recipient or enrollee. Nothing in this paragraph shall
7be construed to limit recipient or enrollee choice to obtain
8new durable medical equipment or place any additional prior
9authorization conditions on enrollees of managed care
10organizations.
11    The Department shall execute, relative to the nursing home
12prescreening project, written inter-agency agreements with the
13Department of Human Services and the Department on Aging, to
14effect the following: (i) intake procedures and common
15eligibility criteria for those persons who are receiving
16non-institutional services; and (ii) the establishment and
17development of non-institutional services in areas of the
18State where they are not currently available or are
19undeveloped; and (iii) notwithstanding any other provision of
20law, subject to federal approval, on and after July 1, 2012, an
21increase in the determination of need (DON) scores from 29 to
2237 for applicants for institutional and home and
23community-based long term care; if and only if federal
24approval is not granted, the Department may, in conjunction
25with other affected agencies, implement utilization controls
26or changes in benefit packages to effectuate a similar savings

 

 

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1amount for this population; and (iv) no later than July 1,
22013, minimum level of care eligibility criteria for
3institutional and home and community-based long term care; and
4(v) no later than October 1, 2013, establish procedures to
5permit long term care providers access to eligibility scores
6for individuals with an admission date who are seeking or
7receiving services from the long term care provider. In order
8to select the minimum level of care eligibility criteria, the
9Governor shall establish a workgroup that includes affected
10agency representatives and stakeholders representing the
11institutional and home and community-based long term care
12interests. This Section shall not restrict the Department from
13implementing lower level of care eligibility criteria for
14community-based services in circumstances where federal
15approval 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
20and programs for monitoring of utilization of health care
21services and facilities, as it affects persons eligible for
22medical assistance 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

 

 

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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 requirement for reporting to the General
12Assembly shall be satisfied by filing copies of the report as
13required by Section 3.1 of the General Assembly Organization
14Act, and filing 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.
18    Rulemaking authority to implement Public Act 95-1045, if
19any, is conditioned on the rules being adopted in accordance
20with all provisions of the Illinois Administrative Procedure
21Act and all rules and procedures of the Joint Committee on
22Administrative Rules; any purported rule not so adopted, for
23whatever reason, is unauthorized.
24    On and after July 1, 2012, the Department shall reduce any
25rate of reimbursement for services or other payments or alter
26any methodologies authorized by this Code to reduce any rate

 

 

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

 

 

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

 

 

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1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5    A federally qualified health center, as defined in Section
61905(l)(2)(B) of the federal Social Security Act, shall be
7reimbursed by the Department in accordance with the federally
8qualified health center's encounter rate for services provided
9to medical assistance recipients that are performed by a
10dental hygienist, as defined under the Illinois Dental
11Practice Act, working under the general supervision of a
12dentist and employed by a federally qualified health center.
13    Within 90 days after October 8, 2021 (the effective date
14of Public Act 102-665) this amendatory Act of the 102nd
15General Assembly, the Department shall seek federal approval
16of a State Plan amendment to expand coverage for family
17planning services that includes presumptive eligibility to
18individuals whose income is at or below 208% of the federal
19poverty level. Coverage under this Section shall be effective
20beginning no later than December 1, 2022.
21    Subject to approval by the federal Centers for Medicare
22and Medicaid Services of a Title XIX State Plan amendment
23electing the Program of All-Inclusive Care for the Elderly
24(PACE) as a State Medicaid option, as provided for by Subtitle
25I (commencing with Section 4801) of Title IV of the Balanced
26Budget Act of 1997 (Public Law 105-33) and Part 460

 

 

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1(commencing with Section 460.2) of Subchapter E of Title 42 of
2the Code of Federal Regulations, PACE program services shall
3become a covered benefit of the medical assistance program,
4subject to criteria established in accordance with all
5applicable laws.
6    Notwithstanding any other provision of this Code,
7community-based pediatric palliative care from a trained
8interdisciplinary team shall be covered under the medical
9assistance program as provided in Section 15 of the Pediatric
10Palliative Care Act.
11(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
12102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1335, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1455-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
15102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
161-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)