Full Text of SB2658 103rd General Assembly
SB2658enr 103RD GENERAL ASSEMBLY | | | SB2658 Enrolled | | LRB103 35285 JAG 65318 b |
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| 1 | | AN ACT concerning health. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 3. The Illinois Public Aid Code is amended by | 5 | | changing Section 5-5 as follows: | 6 | | (305 ILCS 5/5-5) | 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall determine the quantity and quality of and the rate | 9 | | of reimbursement for the medical assistance for which payment | 10 | | will be authorized, and the medical services to be provided, | 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital services; (2) outpatient hospital services; (3) other | 13 | | laboratory and X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians' services whether furnished in the | 15 | | office, the patient's home, a hospital, a skilled nursing | 16 | | home, or elsewhere; (6) medical care, or any other type of | 17 | | remedial care furnished by licensed practitioners; (7) home | 18 | | health care services; (8) private duty nursing service; (9) | 19 | | clinic services; (10) dental services, including prevention | 20 | | and treatment of periodontal disease and dental caries disease | 21 | | for pregnant individuals, provided by an individual licensed | 22 | | to practice dentistry or dental surgery; for purposes of this | 23 | | item (10), "dental services" means diagnostic, preventive, or |
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| 1 | | corrective procedures provided by or under the supervision of | 2 | | a dentist in the practice of his or her profession; (11) | 3 | | physical therapy and related services; (12) prescribed drugs, | 4 | | dentures, and prosthetic devices; and eyeglasses prescribed by | 5 | | a physician skilled in the diseases of the eye, or by an | 6 | | optometrist, whichever the person may select; (13) other | 7 | | diagnostic, screening, preventive, and rehabilitative | 8 | | services, including to ensure that the individual's need for | 9 | | intervention or treatment of mental disorders or substance use | 10 | | disorders or co-occurring mental health and substance use | 11 | | disorders is determined using a uniform screening, assessment, | 12 | | and evaluation process inclusive of criteria, for children and | 13 | | adults; for purposes of this item (13), a uniform screening, | 14 | | assessment, and evaluation process refers to a process that | 15 | | includes an appropriate evaluation and, as warranted, a | 16 | | referral; "uniform" does not mean the use of a singular | 17 | | instrument, tool, or process that all must utilize; (14) | 18 | | transportation and such other expenses as may be necessary; | 19 | | (15) medical treatment of sexual assault survivors, as defined | 20 | | in Section 1a of the Sexual Assault Survivors Emergency | 21 | | Treatment Act, for injuries sustained as a result of the | 22 | | sexual assault, including examinations and laboratory tests to | 23 | | discover evidence which may be used in criminal proceedings | 24 | | arising from the sexual assault; (16) the diagnosis and | 25 | | treatment of sickle cell anemia; (16.5) services performed by | 26 | | a chiropractic physician licensed under the Medical Practice |
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| 1 | | Act of 1987 and acting within the scope of his or her license, | 2 | | including, but not limited to, chiropractic manipulative | 3 | | treatment; and (17) any other medical care, and any other type | 4 | | of remedial care recognized under the laws of this State. The | 5 | | term "any other type of remedial care" shall include nursing | 6 | | care and nursing home service for persons who rely on | 7 | | treatment by spiritual means alone through prayer for healing. | 8 | | Notwithstanding any other provision of this Section, a | 9 | | comprehensive tobacco use cessation program that includes | 10 | | purchasing prescription drugs or prescription medical devices | 11 | | approved by the Food and Drug Administration shall be covered | 12 | | under the medical assistance program under this Article for | 13 | | persons who are otherwise eligible for assistance under this | 14 | | Article. | 15 | | Notwithstanding any other provision of this Code, | 16 | | reproductive health care that is otherwise legal in Illinois | 17 | | shall be covered under the medical assistance program for | 18 | | persons who are otherwise eligible for medical assistance | 19 | | under this Article. | 20 | | Notwithstanding any other provision of this Section, all | 21 | | tobacco cessation medications approved by the United States | 22 | | Food and Drug Administration and all individual and group | 23 | | tobacco cessation counseling services and telephone-based | 24 | | counseling services and tobacco cessation medications provided | 25 | | through the Illinois Tobacco Quitline shall be covered under | 26 | | the medical assistance program for persons who are otherwise |
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| 1 | | eligible for assistance under this Article. The Department | 2 | | shall comply with all federal requirements necessary to obtain | 3 | | federal financial participation, as specified in 42 CFR | 4 | | 433.15(b)(7), for telephone-based counseling services provided | 5 | | through the Illinois Tobacco Quitline, including, but not | 6 | | limited to: (i) entering into a memorandum of understanding or | 7 | | interagency agreement with the Department of Public Health, as | 8 | | administrator of the Illinois Tobacco Quitline; and (ii) | 9 | | developing a cost allocation plan for Medicaid-allowable | 10 | | Illinois Tobacco Quitline services in accordance with 45 CFR | 11 | | 95.507. The Department shall submit the memorandum of | 12 | | understanding or interagency agreement, the cost allocation | 13 | | plan, and all other necessary documentation to the Centers for | 14 | | Medicare and Medicaid Services for review and approval. | 15 | | Coverage under this paragraph shall be contingent upon federal | 16 | | approval. | 17 | | Notwithstanding any other provision of this Code, the | 18 | | Illinois Department may not require, as a condition of payment | 19 | | for any laboratory test authorized under this Article, that a | 20 | | physician's handwritten signature appear on the laboratory | 21 | | test order form. The Illinois Department may, however, impose | 22 | | other appropriate requirements regarding laboratory test order | 23 | | documentation. | 24 | | Upon receipt of federal approval of an amendment to the | 25 | | Illinois Title XIX State Plan for this purpose, the Department | 26 | | shall authorize the Chicago Public Schools (CPS) to procure a |
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| 1 | | vendor or vendors to manufacture eyeglasses for individuals | 2 | | enrolled in a school within the CPS system. CPS shall ensure | 3 | | that its vendor or vendors are enrolled as providers in the | 4 | | medical assistance program and in any capitated Medicaid | 5 | | managed care entity (MCE) serving individuals enrolled in a | 6 | | school within the CPS system. Under any contract procured | 7 | | under this provision, the vendor or vendors must serve only | 8 | | individuals enrolled in a school within the CPS system. Claims | 9 | | for services provided by CPS's vendor or vendors to recipients | 10 | | of benefits in the medical assistance program under this Code, | 11 | | the Children's Health Insurance Program, or the Covering ALL | 12 | | KIDS Health Insurance Program shall be submitted to the | 13 | | Department or the MCE in which the individual is enrolled for | 14 | | payment and shall be reimbursed at the Department's or the | 15 | | MCE's established rates or rate methodologies for eyeglasses. | 16 | | On and after July 1, 2012, the Department of Healthcare | 17 | | and Family Services may provide the following services to | 18 | | persons eligible for assistance under this Article who are | 19 | | participating in education, training or employment programs | 20 | | operated by the Department of Human Services as successor to | 21 | | the Department of Public Aid: | 22 | | (1) dental services provided by or under the | 23 | | supervision of a dentist; and | 24 | | (2) eyeglasses prescribed by a physician skilled in | 25 | | the diseases of the eye, or by an optometrist, whichever | 26 | | the person may select. |
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| 1 | | On and after July 1, 2018, the Department of Healthcare | 2 | | and Family Services shall provide dental services to any adult | 3 | | who is otherwise eligible for assistance under the medical | 4 | | assistance program. As used in this paragraph, "dental | 5 | | services" means diagnostic, preventative, restorative, or | 6 | | corrective procedures, including procedures and services for | 7 | | the prevention and treatment of periodontal disease and dental | 8 | | caries disease, provided by an individual who is licensed to | 9 | | practice dentistry or dental surgery or who is under the | 10 | | supervision of a dentist in the practice of his or her | 11 | | profession. | 12 | | On and after July 1, 2018, targeted dental services, as | 13 | | set forth in Exhibit D of the Consent Decree entered by the | 14 | | United States District Court for the Northern District of | 15 | | Illinois, Eastern Division, in the matter of Memisovski v. | 16 | | Maram, Case No. 92 C 1982, that are provided to adults under | 17 | | the medical assistance program shall be established at no less | 18 | | than the rates set forth in the "New Rate" column in Exhibit D | 19 | | of the Consent Decree for targeted dental services that are | 20 | | provided to persons under the age of 18 under the medical | 21 | | assistance program. | 22 | | Notwithstanding any other provision of this Code and | 23 | | subject to federal approval, the Department may adopt rules to | 24 | | allow a dentist who is volunteering his or her service at no | 25 | | cost to render dental services through an enrolled | 26 | | not-for-profit health clinic without the dentist personally |
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| 1 | | enrolling as a participating provider in the medical | 2 | | assistance program. A not-for-profit health clinic shall | 3 | | include a public health clinic or Federally Qualified Health | 4 | | Center or other enrolled provider, as determined by the | 5 | | Department, through which dental services covered under this | 6 | | Section are performed. The Department shall establish a | 7 | | process for payment of claims for reimbursement for covered | 8 | | dental services rendered under this provision. | 9 | | On and after January 1, 2022, the Department of Healthcare | 10 | | and Family Services shall administer and regulate a | 11 | | school-based dental program that allows for the out-of-office | 12 | | delivery of preventative dental services in a school setting | 13 | | to children under 19 years of age. The Department shall | 14 | | establish, by rule, guidelines for participation by providers | 15 | | and set requirements for follow-up referral care based on the | 16 | | requirements established in the Dental Office Reference Manual | 17 | | published by the Department that establishes the requirements | 18 | | for dentists participating in the All Kids Dental School | 19 | | Program. Every effort shall be made by the Department when | 20 | | developing the program requirements to consider the different | 21 | | geographic differences of both urban and rural areas of the | 22 | | State for initial treatment and necessary follow-up care. No | 23 | | provider shall be charged a fee by any unit of local government | 24 | | to participate in the school-based dental program administered | 25 | | by the Department. Nothing in this paragraph shall be | 26 | | construed to limit or preempt a home rule unit's or school |
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| 1 | | district's authority to establish, change, or administer a | 2 | | school-based dental program in addition to, or independent of, | 3 | | the school-based dental program administered by the | 4 | | Department. | 5 | | The Illinois Department, by rule, may distinguish and | 6 | | classify the medical services to be provided only in | 7 | | accordance with the classes of persons designated in Section | 8 | | 5-2. | 9 | | The Department of Healthcare and Family Services must | 10 | | provide coverage and reimbursement for amino acid-based | 11 | | elemental formulas, regardless of delivery method, for the | 12 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 13 | | short bowel syndrome when the prescribing physician has issued | 14 | | a written order stating that the amino acid-based elemental | 15 | | formula is medically necessary. | 16 | | The Illinois Department shall authorize the provision of, | 17 | | and shall authorize payment for, screening by low-dose | 18 | | mammography for the presence of occult breast cancer for | 19 | | individuals 35 years of age or older who are eligible for | 20 | | medical assistance under this Article, as follows: | 21 | | (A) A baseline mammogram for individuals 35 to 39 | 22 | | years of age. | 23 | | (B) An annual mammogram for individuals 40 years of | 24 | | age or older. | 25 | | (C) A mammogram at the age and intervals considered | 26 | | medically necessary by the individual's health care |
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| 1 | | provider for individuals under 40 years of age and having | 2 | | a family history of breast cancer, prior personal history | 3 | | of breast cancer, positive genetic testing, or other risk | 4 | | factors. | 5 | | (D) A comprehensive ultrasound screening and MRI of an | 6 | | entire breast or breasts if a mammogram demonstrates | 7 | | heterogeneous or dense breast tissue or when medically | 8 | | necessary as determined by a physician licensed to | 9 | | practice medicine in all of its branches. | 10 | | (E) A screening MRI when medically necessary, as | 11 | | determined by a physician licensed to practice medicine in | 12 | | all of its branches. | 13 | | (F) A diagnostic mammogram when medically necessary, | 14 | | as determined by a physician licensed to practice medicine | 15 | | in all its branches, advanced practice registered nurse, | 16 | | or physician assistant. | 17 | | The Department shall not impose a deductible, coinsurance, | 18 | | copayment, or any other cost-sharing requirement on the | 19 | | coverage provided under this paragraph; except that this | 20 | | sentence does not apply to coverage of diagnostic mammograms | 21 | | to the extent such coverage would disqualify a high-deductible | 22 | | health plan from eligibility for a health savings account | 23 | | pursuant to Section 223 of the Internal Revenue Code (26 | 24 | | U.S.C. 223). | 25 | | All screenings shall include a physical breast exam, | 26 | | instruction on self-examination and information regarding the |
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| 1 | | frequency of self-examination and its value as a preventative | 2 | | tool. | 3 | | For purposes of this Section: | 4 | | "Diagnostic mammogram" means a mammogram obtained using | 5 | | diagnostic mammography. | 6 | | "Diagnostic mammography" means a method of screening that | 7 | | is designed to evaluate an abnormality in a breast, including | 8 | | an abnormality seen or suspected on a screening mammogram or a | 9 | | subjective or objective abnormality otherwise detected in the | 10 | | breast. | 11 | | "Low-dose mammography" means the x-ray examination of the | 12 | | breast using equipment dedicated specifically for mammography, | 13 | | including the x-ray tube, filter, compression device, and | 14 | | image receptor, with an average radiation exposure delivery of | 15 | | less than one rad per breast for 2 views of an average size | 16 | | breast. The term also includes digital mammography and | 17 | | includes breast tomosynthesis. | 18 | | "Breast tomosynthesis" means a radiologic procedure that | 19 | | involves the acquisition of projection images over the | 20 | | stationary breast to produce cross-sectional digital | 21 | | three-dimensional images of the breast. | 22 | | If, at any time, the Secretary of the United States | 23 | | Department of Health and Human Services, or its successor | 24 | | agency, promulgates rules or regulations to be published in | 25 | | the Federal Register or publishes a comment in the Federal | 26 | | Register or issues an opinion, guidance, or other action that |
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| 1 | | would require the State, pursuant to any provision of the | 2 | | Patient Protection and Affordable Care Act (Public Law | 3 | | 111-148), including, but not limited to, 42 U.S.C. | 4 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 5 | | of any coverage for breast tomosynthesis outlined in this | 6 | | paragraph, then the requirement that an insurer cover breast | 7 | | tomosynthesis is inoperative other than any such coverage | 8 | | authorized under Section 1902 of the Social Security Act, 42 | 9 | | U.S.C. 1396a, and the State shall not assume any obligation | 10 | | for the cost of coverage for breast tomosynthesis set forth in | 11 | | this paragraph. | 12 | | On and after January 1, 2016, the Department shall ensure | 13 | | that all networks of care for adult clients of the Department | 14 | | include access to at least one breast imaging Center of | 15 | | Imaging Excellence as certified by the American College of | 16 | | Radiology. | 17 | | On and after January 1, 2012, providers participating in a | 18 | | quality improvement program approved by the Department shall | 19 | | be reimbursed for screening and diagnostic mammography at the | 20 | | same rate as the Medicare program's rates, including the | 21 | | increased reimbursement for digital mammography and, after | 22 | | January 1, 2023 (the effective date of Public Act 102-1018), | 23 | | breast tomosynthesis. | 24 | | The Department shall convene an expert panel including | 25 | | representatives of hospitals, free-standing mammography | 26 | | facilities, and doctors, including radiologists, to establish |
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| 1 | | quality standards for mammography. | 2 | | On and after January 1, 2017, providers participating in a | 3 | | breast cancer treatment quality improvement program approved | 4 | | by the Department shall be reimbursed for breast cancer | 5 | | treatment at a rate that is no lower than 95% of the Medicare | 6 | | program's rates for the data elements included in the breast | 7 | | cancer treatment quality program. | 8 | | The Department shall convene an expert panel, including | 9 | | representatives of hospitals, free-standing breast cancer | 10 | | treatment centers, breast cancer quality organizations, and | 11 | | doctors, including breast surgeons, reconstructive breast | 12 | | surgeons, oncologists, and primary care providers to establish | 13 | | quality standards for breast cancer treatment. | 14 | | Subject to federal approval, the Department shall | 15 | | establish a rate methodology for mammography at federally | 16 | | qualified health centers and other encounter-rate clinics. | 17 | | These clinics or centers may also collaborate with other | 18 | | hospital-based mammography facilities. By January 1, 2016, the | 19 | | Department shall report to the General Assembly on the status | 20 | | of the provision set forth in this paragraph. | 21 | | The Department shall establish a methodology to remind | 22 | | individuals who are age-appropriate for screening mammography, | 23 | | but who have not received a mammogram within the previous 18 | 24 | | months, of the importance and benefit of screening | 25 | | mammography. The Department shall work with experts in breast | 26 | | cancer outreach and patient navigation to optimize these |
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| 1 | | reminders and shall establish a methodology for evaluating | 2 | | their effectiveness and modifying the methodology based on the | 3 | | evaluation. | 4 | | The Department shall establish a performance goal for | 5 | | primary care providers with respect to their female patients | 6 | | over age 40 receiving an annual mammogram. This performance | 7 | | goal shall be used to provide additional reimbursement in the | 8 | | form of a quality performance bonus to primary care providers | 9 | | who meet that goal. | 10 | | The Department shall devise a means of case-managing or | 11 | | patient navigation for beneficiaries diagnosed with breast | 12 | | cancer. This program shall initially operate as a pilot | 13 | | program in areas of the State with the highest incidence of | 14 | | mortality related to breast cancer. At least one pilot program | 15 | | site shall be in the metropolitan Chicago area and at least one | 16 | | site shall be outside the metropolitan Chicago area. On or | 17 | | after July 1, 2016, the pilot program shall be expanded to | 18 | | include one site in western Illinois, one site in southern | 19 | | Illinois, one site in central Illinois, and 4 sites within | 20 | | metropolitan Chicago. An evaluation of the pilot program shall | 21 | | be carried out measuring health outcomes and cost of care for | 22 | | those served by the pilot program compared to similarly | 23 | | situated patients who are not served by the pilot program. | 24 | | The Department shall require all networks of care to | 25 | | develop a means either internally or by contract with experts | 26 | | in navigation and community outreach to navigate cancer |
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| 1 | | patients to comprehensive care in a timely fashion. The | 2 | | Department shall require all networks of care to include | 3 | | access for patients diagnosed with cancer to at least one | 4 | | academic commission on cancer-accredited cancer program as an | 5 | | in-network covered benefit. | 6 | | The Department shall provide coverage and reimbursement | 7 | | for a human papillomavirus (HPV) vaccine that is approved for | 8 | | marketing by the federal Food and Drug Administration for all | 9 | | persons between the ages of 9 and 45. Subject to federal | 10 | | approval, the Department shall provide coverage and | 11 | | reimbursement for a human papillomavirus (HPV) vaccine for | 12 | | persons of the age of 46 and above who have been diagnosed with | 13 | | cervical dysplasia with a high risk of recurrence or | 14 | | progression. The Department shall disallow any | 15 | | preauthorization requirements for the administration of the | 16 | | human papillomavirus (HPV) vaccine. | 17 | | On or after July 1, 2022, individuals who are otherwise | 18 | | eligible for medical assistance under this Article shall | 19 | | receive coverage for perinatal depression screenings for the | 20 | | 12-month period beginning on the last day of their pregnancy. | 21 | | Medical assistance coverage under this paragraph shall be | 22 | | conditioned on the use of a screening instrument approved by | 23 | | the Department. | 24 | | Any medical or health care provider shall immediately | 25 | | recommend, to any pregnant individual who is being provided | 26 | | prenatal services and is suspected of having a substance use |
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| 1 | | disorder as defined in the Substance Use Disorder Act, | 2 | | referral to a local substance use disorder treatment program | 3 | | licensed by the Department of Human Services or to a licensed | 4 | | hospital which provides substance abuse treatment services. | 5 | | The Department of Healthcare and Family Services shall assure | 6 | | coverage for the cost of treatment of the drug abuse or | 7 | | addiction for pregnant recipients in accordance with the | 8 | | Illinois Medicaid Program in conjunction with the Department | 9 | | of Human Services. | 10 | | All medical providers providing medical assistance to | 11 | | pregnant individuals under this Code shall receive information | 12 | | from the Department on the availability of services under any | 13 | | program providing case management services for addicted | 14 | | individuals, including information on appropriate referrals | 15 | | for other social services that may be needed by addicted | 16 | | individuals in addition to treatment for addiction. | 17 | | The Illinois Department, in cooperation with the | 18 | | Departments of Human Services (as successor to the Department | 19 | | of Alcoholism and Substance Abuse) and Public Health, through | 20 | | a public awareness campaign, may provide information | 21 | | concerning treatment for alcoholism and drug abuse and | 22 | | addiction, prenatal health care, and other pertinent programs | 23 | | directed at reducing the number of drug-affected infants born | 24 | | to recipients of medical assistance. | 25 | | Neither the Department of Healthcare and Family Services | 26 | | nor the Department of Human Services shall sanction the |
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| 1 | | recipient solely on the basis of the recipient's substance | 2 | | abuse. | 3 | | The Illinois Department shall establish such regulations | 4 | | governing the dispensing of health services under this Article | 5 | | as it shall deem appropriate. The Department should seek the | 6 | | advice of formal professional advisory committees appointed by | 7 | | the Director of the Illinois Department for the purpose of | 8 | | providing regular advice on policy and administrative matters, | 9 | | information dissemination and educational activities for | 10 | | medical and health care providers, and consistency in | 11 | | procedures to the Illinois Department. | 12 | | The Illinois Department may develop and contract with | 13 | | Partnerships of medical providers to arrange medical services | 14 | | for persons eligible under Section 5-2 of this Code. | 15 | | Implementation of this Section may be by demonstration | 16 | | projects in certain geographic areas. The Partnership shall be | 17 | | represented by a sponsor organization. The Department, by | 18 | | rule, shall develop qualifications for sponsors of | 19 | | Partnerships. Nothing in this Section shall be construed to | 20 | | require that the sponsor organization be a medical | 21 | | organization. | 22 | | The sponsor must negotiate formal written contracts with | 23 | | medical providers for physician services, inpatient and | 24 | | outpatient hospital care, home health services, treatment for | 25 | | alcoholism and substance abuse, and other services determined | 26 | | necessary by the Illinois Department by rule for delivery by |
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| 1 | | Partnerships. Physician services must include prenatal and | 2 | | obstetrical care. The Illinois Department shall reimburse | 3 | | medical services delivered by Partnership providers to clients | 4 | | in target areas according to provisions of this Article and | 5 | | the Illinois Health Finance Reform Act, except that: | 6 | | (1) Physicians participating in a Partnership and | 7 | | providing certain services, which shall be determined by | 8 | | the Illinois Department, to persons in areas covered by | 9 | | the Partnership may receive an additional surcharge for | 10 | | such services. | 11 | | (2) The Department may elect to consider and negotiate | 12 | | financial incentives to encourage the development of | 13 | | Partnerships and the efficient delivery of medical care. | 14 | | (3) Persons receiving medical services through | 15 | | Partnerships may receive medical and case management | 16 | | services above the level usually offered through the | 17 | | medical assistance program. | 18 | | Medical providers shall be required to meet certain | 19 | | qualifications to participate in Partnerships to ensure the | 20 | | delivery of high quality medical services. These | 21 | | qualifications shall be determined by rule of the Illinois | 22 | | Department and may be higher than qualifications for | 23 | | participation in the medical assistance program. Partnership | 24 | | sponsors may prescribe reasonable additional qualifications | 25 | | for participation by medical providers, only with the prior | 26 | | written approval of the Illinois Department. |
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| 1 | | Nothing in this Section shall limit the free choice of | 2 | | practitioners, hospitals, and other providers of medical | 3 | | services by clients. In order to ensure patient freedom of | 4 | | choice, the Illinois Department shall immediately promulgate | 5 | | all rules and take all other necessary actions so that | 6 | | provided services may be accessed from therapeutically | 7 | | certified optometrists to the full extent of the Illinois | 8 | | Optometric Practice Act of 1987 without discriminating between | 9 | | service providers. | 10 | | The Department shall apply for a waiver from the United | 11 | | States Health Care Financing Administration to allow for the | 12 | | implementation of Partnerships under this Section. | 13 | | The Illinois Department shall require health care | 14 | | providers to maintain records that document the medical care | 15 | | and services provided to recipients of Medical Assistance | 16 | | under this Article. Such records must be retained for a period | 17 | | of not less than 6 years from the date of service or as | 18 | | provided by applicable State law, whichever period is longer, | 19 | | except that if an audit is initiated within the required | 20 | | retention period then the records must be retained until the | 21 | | audit is completed and every exception is resolved. The | 22 | | Illinois Department shall require health care providers to | 23 | | make available, when authorized by the patient, in writing, | 24 | | the medical records in a timely fashion to other health care | 25 | | providers who are treating or serving persons eligible for | 26 | | Medical Assistance under this Article. All dispensers of |
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| 1 | | medical services shall be required to maintain and retain | 2 | | business and professional records sufficient to fully and | 3 | | accurately document the nature, scope, details and receipt of | 4 | | the health care provided to persons eligible for medical | 5 | | assistance under this Code, in accordance with regulations | 6 | | promulgated by the Illinois Department. The rules and | 7 | | regulations shall require that proof of the receipt of | 8 | | prescription drugs, dentures, prosthetic devices and | 9 | | eyeglasses by eligible persons under this Section accompany | 10 | | each claim for reimbursement submitted by the dispenser of | 11 | | such medical services. No such claims for reimbursement shall | 12 | | be approved for payment by the Illinois Department without | 13 | | such proof of receipt, unless the Illinois Department shall | 14 | | have put into effect and shall be operating a system of | 15 | | post-payment audit and review which shall, on a sampling | 16 | | basis, be deemed adequate by the Illinois Department to assure | 17 | | that such drugs, dentures, prosthetic devices and eyeglasses | 18 | | for which payment is being made are actually being received by | 19 | | eligible recipients. Within 90 days after September 16, 1984 | 20 | | (the effective date of Public Act 83-1439), the Illinois | 21 | | Department shall establish a current list of acquisition costs | 22 | | for all prosthetic devices and any other items recognized as | 23 | | medical equipment and supplies reimbursable under this Article | 24 | | and shall update such list on a quarterly basis, except that | 25 | | the acquisition costs of all prescription drugs shall be | 26 | | updated no less frequently than every 30 days as required by |
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| 1 | | Section 5-5.12. | 2 | | Notwithstanding any other law to the contrary, the | 3 | | Illinois Department shall, within 365 days after July 22, 2013 | 4 | | (the effective date of Public Act 98-104), establish | 5 | | procedures to permit skilled care facilities licensed under | 6 | | the Nursing Home Care Act to submit monthly billing claims for | 7 | | reimbursement purposes. Following development of these | 8 | | procedures, the Department shall, by July 1, 2016, test the | 9 | | viability of the new system and implement any necessary | 10 | | operational or structural changes to its information | 11 | | technology platforms in order to allow for the direct | 12 | | acceptance and payment of nursing home claims. | 13 | | Notwithstanding any other law to the contrary, the | 14 | | Illinois Department shall, within 365 days after August 15, | 15 | | 2014 (the effective date of Public Act 98-963), establish | 16 | | procedures to permit ID/DD facilities licensed under the ID/DD | 17 | | Community Care Act and MC/DD facilities licensed under the | 18 | | MC/DD Act to submit monthly billing claims for reimbursement | 19 | | purposes. Following development of these procedures, the | 20 | | Department shall have an additional 365 days to test the | 21 | | viability of the new system and to ensure that any necessary | 22 | | operational or structural changes to its information | 23 | | technology platforms are implemented. | 24 | | The Illinois Department shall require all dispensers of | 25 | | medical services, other than an individual practitioner or | 26 | | group of practitioners, desiring to participate in the Medical |
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| 1 | | Assistance program established under this Article to disclose | 2 | | all financial, beneficial, ownership, equity, surety or other | 3 | | interests in any and all firms, corporations, partnerships, | 4 | | associations, business enterprises, joint ventures, agencies, | 5 | | institutions or other legal entities providing any form of | 6 | | health care services in this State under this Article. | 7 | | The Illinois Department may require that all dispensers of | 8 | | medical services desiring to participate in the medical | 9 | | assistance program established under this Article disclose, | 10 | | under such terms and conditions as the Illinois Department may | 11 | | by rule establish, all inquiries from clients and attorneys | 12 | | regarding medical bills paid by the Illinois Department, which | 13 | | inquiries could indicate potential existence of claims or | 14 | | liens for the Illinois Department. | 15 | | Enrollment of a vendor shall be subject to a provisional | 16 | | period and shall be conditional for one year. During the | 17 | | period of conditional enrollment, the Department may terminate | 18 | | the vendor's eligibility to participate in, or may disenroll | 19 | | the vendor from, the medical assistance program without cause. | 20 | | Unless otherwise specified, such termination of eligibility or | 21 | | disenrollment is not subject to the Department's hearing | 22 | | process. However, a disenrolled vendor may reapply without | 23 | | penalty. | 24 | | The Department has the discretion to limit the conditional | 25 | | enrollment period for vendors based upon the category of risk | 26 | | of the vendor. |
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| 1 | | Prior to enrollment and during the conditional enrollment | 2 | | period in the medical assistance program, all vendors shall be | 3 | | subject to enhanced oversight, screening, and review based on | 4 | | the risk of fraud, waste, and abuse that is posed by the | 5 | | category of risk of the vendor. The Illinois Department shall | 6 | | establish the procedures for oversight, screening, and review, | 7 | | which may include, but need not be limited to: criminal and | 8 | | financial background checks; fingerprinting; license, | 9 | | certification, and authorization verifications; unscheduled or | 10 | | unannounced site visits; database checks; prepayment audit | 11 | | reviews; audits; payment caps; payment suspensions; and other | 12 | | screening as required by federal or State law. | 13 | | The Department shall define or specify the following: (i) | 14 | | by provider notice, the "category of risk of the vendor" for | 15 | | each type of vendor, which shall take into account the level of | 16 | | screening applicable to a particular category of vendor under | 17 | | federal law and regulations; (ii) by rule or provider notice, | 18 | | the maximum length of the conditional enrollment period for | 19 | | each category of risk of the vendor; and (iii) by rule, the | 20 | | hearing rights, if any, afforded to a vendor in each category | 21 | | of risk of the vendor that is terminated or disenrolled during | 22 | | the conditional enrollment period. | 23 | | To be eligible for payment consideration, a vendor's | 24 | | payment claim or bill, either as an initial claim or as a | 25 | | resubmitted claim following prior rejection, must be received | 26 | | by the Illinois Department, or its fiscal intermediary, no |
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| 1 | | later than 180 days after the latest date on the claim on which | 2 | | medical goods or services were provided, with the following | 3 | | exceptions: | 4 | | (1) In the case of a provider whose enrollment is in | 5 | | process by the Illinois Department, the 180-day period | 6 | | shall not begin until the date on the written notice from | 7 | | the Illinois Department that the provider enrollment is | 8 | | complete. | 9 | | (2) In the case of errors attributable to the Illinois | 10 | | Department or any of its claims processing intermediaries | 11 | | which result in an inability to receive, process, or | 12 | | adjudicate a claim, the 180-day period shall not begin | 13 | | until the provider has been notified of the error. | 14 | | (3) In the case of a provider for whom the Illinois | 15 | | Department initiates the monthly billing process. | 16 | | (4) In the case of a provider operated by a unit of | 17 | | local government with a population exceeding 3,000,000 | 18 | | when local government funds finance federal participation | 19 | | for claims payments. | 20 | | For claims for services rendered during a period for which | 21 | | a recipient received retroactive eligibility, claims must be | 22 | | filed within 180 days after the Department determines the | 23 | | applicant is eligible. For claims for which the Illinois | 24 | | Department is not the primary payer, claims must be submitted | 25 | | to the Illinois Department within 180 days after the final | 26 | | adjudication by the primary payer. |
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| 1 | | In the case of long term care facilities, within 120 | 2 | | calendar days of receipt by the facility of required | 3 | | prescreening information, new admissions with associated | 4 | | admission documents shall be submitted through the Medical | 5 | | Electronic Data Interchange (MEDI) or the Recipient | 6 | | Eligibility Verification (REV) System or shall be submitted | 7 | | directly to the Department of Human Services using required | 8 | | admission forms. Effective September 1, 2014, admission | 9 | | documents, including all prescreening information, must be | 10 | | submitted through MEDI or REV. Confirmation numbers assigned | 11 | | to an accepted transaction shall be retained by a facility to | 12 | | verify timely submittal. Once an admission transaction has | 13 | | been completed, all resubmitted claims following prior | 14 | | rejection are subject to receipt no later than 180 days after | 15 | | the admission transaction has been completed. | 16 | | Claims that are not submitted and received in compliance | 17 | | with the foregoing requirements shall not be eligible for | 18 | | payment under the medical assistance program, and the State | 19 | | shall have no liability for payment of those claims. | 20 | | To the extent consistent with applicable information and | 21 | | privacy, security, and disclosure laws, State and federal | 22 | | agencies and departments shall provide the Illinois Department | 23 | | access to confidential and other information and data | 24 | | necessary to perform eligibility and payment verifications and | 25 | | other Illinois Department functions. This includes, but is not | 26 | | limited to: information pertaining to licensure; |
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| 1 | | certification; earnings; immigration status; citizenship; wage | 2 | | reporting; unearned and earned income; pension income; | 3 | | employment; supplemental security income; social security | 4 | | numbers; National Provider Identifier (NPI) numbers; the | 5 | | National Practitioner Data Bank (NPDB); program and agency | 6 | | exclusions; taxpayer identification numbers; tax delinquency; | 7 | | corporate information; and death records. | 8 | | The Illinois Department shall enter into agreements with | 9 | | State agencies and departments, and is authorized to enter | 10 | | into agreements with federal agencies and departments, under | 11 | | which such agencies and departments shall share data necessary | 12 | | for medical assistance program integrity functions and | 13 | | oversight. The Illinois Department shall develop, in | 14 | | cooperation with other State departments and agencies, and in | 15 | | compliance with applicable federal laws and regulations, | 16 | | appropriate and effective methods to share such data. At a | 17 | | minimum, and to the extent necessary to provide data sharing, | 18 | | the Illinois Department shall enter into agreements with State | 19 | | agencies and departments, and is authorized to enter into | 20 | | agreements with federal agencies and departments, including, | 21 | | but not limited to: the Secretary of State; the Department of | 22 | | Revenue; the Department of Public Health; the Department of | 23 | | Human Services; and the Department of Financial and | 24 | | Professional Regulation. | 25 | | Beginning in fiscal year 2013, the Illinois Department | 26 | | shall set forth a request for information to identify the |
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| 1 | | benefits of a pre-payment, post-adjudication, and post-edit | 2 | | claims system with the goals of streamlining claims processing | 3 | | and provider reimbursement, reducing the number of pending or | 4 | | rejected claims, and helping to ensure a more transparent | 5 | | adjudication process through the utilization of: (i) provider | 6 | | data verification and provider screening technology; and (ii) | 7 | | clinical code editing; and (iii) pre-pay, pre-adjudicated , or | 8 | | post-adjudicated predictive modeling with an integrated case | 9 | | management system with link analysis. Such a request for | 10 | | information shall not be considered as a request for proposal | 11 | | or as an obligation on the part of the Illinois Department to | 12 | | take any action or acquire any products or services. | 13 | | The Illinois Department shall establish policies, | 14 | | procedures, standards and criteria by rule for the | 15 | | acquisition, repair and replacement of orthotic and prosthetic | 16 | | devices and durable medical equipment. Such rules shall | 17 | | provide, but not be limited to, the following services: (1) | 18 | | immediate repair or replacement of such devices by recipients; | 19 | | and (2) rental, lease, purchase or lease-purchase of durable | 20 | | medical equipment in a cost-effective manner, taking into | 21 | | consideration the recipient's medical prognosis, the extent of | 22 | | the recipient's needs, and the requirements and costs for | 23 | | maintaining such equipment. Subject to prior approval, such | 24 | | rules shall enable a recipient to temporarily acquire and use | 25 | | alternative or substitute devices or equipment pending repairs | 26 | | or replacements of any device or equipment previously |
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| 1 | | authorized for such recipient by the Department. | 2 | | Notwithstanding any provision of Section 5-5f to the contrary, | 3 | | the Department may, by rule, exempt certain replacement | 4 | | wheelchair parts from prior approval and, for wheelchairs, | 5 | | wheelchair parts, wheelchair accessories, and related seating | 6 | | and positioning items, determine the wholesale price by | 7 | | methods other than actual acquisition costs. | 8 | | The Department shall require, by rule, all providers of | 9 | | durable medical equipment to be accredited by an accreditation | 10 | | organization approved by the federal Centers for Medicare and | 11 | | Medicaid Services and recognized by the Department in order to | 12 | | bill the Department for providing durable medical equipment to | 13 | | recipients. No later than 15 months after the effective date | 14 | | of the rule adopted pursuant to this paragraph, all providers | 15 | | must meet the accreditation requirement. | 16 | | In order to promote environmental responsibility, meet the | 17 | | needs of recipients and enrollees, and achieve significant | 18 | | cost savings, the Department, or a managed care organization | 19 | | under contract with the Department, may provide recipients or | 20 | | managed care enrollees who have a prescription or Certificate | 21 | | of Medical Necessity access to refurbished durable medical | 22 | | equipment under this Section (excluding prosthetic and | 23 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 24 | | Pedorthics Practice Act and complex rehabilitation technology | 25 | | products and associated services) through the State's | 26 | | assistive technology program's reutilization program, using |
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| 1 | | staff with the Assistive Technology Professional (ATP) | 2 | | Certification if the refurbished durable medical equipment: | 3 | | (i) is available; (ii) is less expensive, including shipping | 4 | | costs, than new durable medical equipment of the same type; | 5 | | (iii) is able to withstand at least 3 years of use; (iv) is | 6 | | cleaned, disinfected, sterilized, and safe in accordance with | 7 | | federal Food and Drug Administration regulations and guidance | 8 | | governing the reprocessing of medical devices in health care | 9 | | settings; and (v) equally meets the needs of the recipient or | 10 | | enrollee. The reutilization program shall confirm that the | 11 | | recipient or enrollee is not already in receipt of the same or | 12 | | similar equipment from another service provider, and that the | 13 | | refurbished durable medical equipment equally meets the needs | 14 | | of the recipient or enrollee. Nothing in this paragraph shall | 15 | | be construed to limit recipient or enrollee choice to obtain | 16 | | new durable medical equipment or place any additional prior | 17 | | authorization conditions on enrollees of managed care | 18 | | organizations. | 19 | | The Department shall execute, relative to the nursing home | 20 | | prescreening project, written inter-agency agreements with the | 21 | | Department of Human Services and the Department on Aging, to | 22 | | effect the following: (i) intake procedures and common | 23 | | eligibility criteria for those persons who are receiving | 24 | | non-institutional services; and (ii) the establishment and | 25 | | development of non-institutional services in areas of the | 26 | | State where they are not currently available or are |
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| 1 | | undeveloped; and (iii) notwithstanding any other provision of | 2 | | law, subject to federal approval, on and after July 1, 2012, an | 3 | | increase in the determination of need (DON) scores from 29 to | 4 | | 37 for applicants for institutional and home and | 5 | | community-based long term care; if and only if federal | 6 | | approval is not granted, the Department may, in conjunction | 7 | | with other affected agencies, implement utilization controls | 8 | | or changes in benefit packages to effectuate a similar savings | 9 | | amount for this population; and (iv) no later than July 1, | 10 | | 2013, minimum level of care eligibility criteria for | 11 | | institutional and home and community-based long term care; and | 12 | | (v) no later than October 1, 2013, establish procedures to | 13 | | permit long term care providers access to eligibility scores | 14 | | for individuals with an admission date who are seeking or | 15 | | receiving services from the long term care provider. In order | 16 | | to select the minimum level of care eligibility criteria, the | 17 | | Governor shall establish a workgroup that includes affected | 18 | | agency representatives and stakeholders representing the | 19 | | institutional and home and community-based long term care | 20 | | interests. This Section shall not restrict the Department from | 21 | | implementing lower level of care eligibility criteria for | 22 | | community-based services in circumstances where federal | 23 | | approval has been granted. | 24 | | The Illinois Department shall develop and operate, in | 25 | | cooperation with other State Departments and agencies and in | 26 | | compliance with applicable federal laws and regulations, |
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| 1 | | appropriate and effective systems of health care evaluation | 2 | | and programs for monitoring of utilization of health care | 3 | | services and facilities, as it affects persons eligible for | 4 | | medical assistance under this Code. | 5 | | The Illinois Department shall report annually to the | 6 | | General Assembly, no later than the second Friday in April of | 7 | | 1979 and each year thereafter, in regard to: | 8 | | (a) actual statistics and trends in utilization of | 9 | | medical services by public aid recipients; | 10 | | (b) actual statistics and trends in the provision of | 11 | | the various medical services by medical vendors; | 12 | | (c) current rate structures and proposed changes in | 13 | | those rate structures for the various medical vendors; and | 14 | | (d) efforts at utilization review and control by the | 15 | | Illinois Department. | 16 | | The period covered by each report shall be the 3 years | 17 | | ending on the June 30 prior to the report. The report shall | 18 | | include suggested legislation for consideration by the General | 19 | | Assembly. The requirement for reporting to the General | 20 | | Assembly shall be satisfied by filing copies of the report as | 21 | | required by Section 3.1 of the General Assembly Organization | 22 | | Act, and filing such additional copies with the State | 23 | | Government Report Distribution Center for the General Assembly | 24 | | as is required under paragraph (t) of Section 7 of the State | 25 | | Library Act. | 26 | | Rulemaking authority to implement Public Act 95-1045, if |
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| 1 | | any, is conditioned on the rules being adopted in accordance | 2 | | with all provisions of the Illinois Administrative Procedure | 3 | | Act and all rules and procedures of the Joint Committee on | 4 | | Administrative Rules; any purported rule not so adopted, for | 5 | | whatever reason, is unauthorized. | 6 | | On and after July 1, 2012, the Department shall reduce any | 7 | | rate of reimbursement for services or other payments or alter | 8 | | any methodologies authorized by this Code to reduce any rate | 9 | | of reimbursement for services or other payments in accordance | 10 | | with Section 5-5e. | 11 | | Because kidney transplantation can be an appropriate, | 12 | | cost-effective alternative to renal dialysis when medically | 13 | | necessary and notwithstanding the provisions of Section 1-11 | 14 | | of this Code, beginning October 1, 2014, the Department shall | 15 | | cover kidney transplantation for noncitizens with end-stage | 16 | | renal disease who are not eligible for comprehensive medical | 17 | | benefits, who meet the residency requirements of Section 5-3 | 18 | | of this Code, and who would otherwise meet the financial | 19 | | requirements of the appropriate class of eligible persons | 20 | | under Section 5-2 of this Code. To qualify for coverage of | 21 | | kidney transplantation, such person must be receiving | 22 | | emergency renal dialysis services covered by the Department. | 23 | | Providers under this Section shall be prior approved and | 24 | | certified by the Department to perform kidney transplantation | 25 | | and the services under this Section shall be limited to | 26 | | services associated with kidney transplantation. |
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| 1 | | Notwithstanding any other provision of this Code to the | 2 | | contrary, on or after July 1, 2015, all FDA approved forms of | 3 | | medication assisted treatment prescribed for the treatment of | 4 | | alcohol dependence or treatment of opioid dependence shall be | 5 | | covered under both fee-for-service fee for service and managed | 6 | | care medical assistance programs for persons who are otherwise | 7 | | eligible for medical assistance under this Article and shall | 8 | | not be subject to any (1) utilization control, other than | 9 | | those established under the American Society of Addiction | 10 | | Medicine patient placement criteria, (2) prior authorization | 11 | | mandate, or (3) lifetime restriction limit mandate. | 12 | | On or after July 1, 2015, opioid antagonists prescribed | 13 | | for the treatment of an opioid overdose, including the | 14 | | medication product, administration devices, and any pharmacy | 15 | | fees or hospital fees related to the dispensing, distribution, | 16 | | and administration of the opioid antagonist, shall be covered | 17 | | under the medical assistance program for persons who are | 18 | | otherwise eligible for medical assistance under this Article. | 19 | | As used in this Section, "opioid antagonist" means a drug that | 20 | | binds to opioid receptors and blocks or inhibits the effect of | 21 | | opioids acting on those receptors, including, but not limited | 22 | | to, naloxone hydrochloride or any other similarly acting drug | 23 | | approved by the U.S. Food and Drug Administration. The | 24 | | Department shall not impose a copayment on the coverage | 25 | | provided for naloxone hydrochloride under the medical | 26 | | assistance program. |
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| 1 | | Upon federal approval, the Department shall provide | 2 | | coverage and reimbursement for all drugs that are approved for | 3 | | marketing by the federal Food and Drug Administration and that | 4 | | are recommended by the federal Public Health Service or the | 5 | | United States Centers for Disease Control and Prevention for | 6 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 7 | | services, including, but not limited to, HIV and sexually | 8 | | transmitted infection screening, treatment for sexually | 9 | | transmitted infections, medical monitoring, assorted labs, and | 10 | | counseling to reduce the likelihood of HIV infection among | 11 | | individuals who are not infected with HIV but who are at high | 12 | | risk of HIV infection. | 13 | | A federally qualified health center, as defined in Section | 14 | | 1905(l)(2)(B) of the federal Social Security Act, shall be | 15 | | reimbursed by the Department in accordance with the federally | 16 | | qualified health center's encounter rate for services provided | 17 | | to medical assistance recipients that are performed by a | 18 | | dental hygienist, as defined under the Illinois Dental | 19 | | Practice Act, working under the general supervision of a | 20 | | dentist and employed by a federally qualified health center. | 21 | | Within 90 days after October 8, 2021 (the effective date | 22 | | of Public Act 102-665), the Department shall seek federal | 23 | | approval of a State Plan amendment to expand coverage for | 24 | | family planning services that includes presumptive eligibility | 25 | | to individuals whose income is at or below 208% of the federal | 26 | | poverty level. Coverage under this Section shall be effective |
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| 1 | | beginning no later than December 1, 2022. | 2 | | Subject to approval by the federal Centers for Medicare | 3 | | and Medicaid Services of a Title XIX State Plan amendment | 4 | | electing the Program of All-Inclusive Care for the Elderly | 5 | | (PACE) as a State Medicaid option, as provided for by Subtitle | 6 | | I (commencing with Section 4801) of Title IV of the Balanced | 7 | | Budget Act of 1997 (Public Law 105-33) and Part 460 | 8 | | (commencing with Section 460.2) of Subchapter E of Title 42 of | 9 | | the Code of Federal Regulations, PACE program services shall | 10 | | become a covered benefit of the medical assistance program, | 11 | | subject to criteria established in accordance with all | 12 | | applicable laws. | 13 | | Notwithstanding any other provision of this Code, | 14 | | community-based pediatric palliative care from a trained | 15 | | interdisciplinary team shall be covered under the medical | 16 | | assistance program as provided in Section 15 of the Pediatric | 17 | | Palliative Care Act. | 18 | | Notwithstanding any other provision of this Code, within | 19 | | 12 months after June 2, 2022 (the effective date of Public Act | 20 | | 102-1037) and subject to federal approval, acupuncture | 21 | | services performed by an acupuncturist licensed under the | 22 | | Acupuncture Practice Act who is acting within the scope of his | 23 | | or her license shall be covered under the medical assistance | 24 | | program. The Department shall apply for any federal waiver or | 25 | | State Plan amendment, if required, to implement this | 26 | | paragraph. The Department may adopt any rules, including |
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| 1 | | standards and criteria, necessary to implement this paragraph. | 2 | | Notwithstanding any other provision of this Code, the | 3 | | medical assistance program shall, subject to appropriation and | 4 | | federal approval, reimburse hospitals for costs associated | 5 | | with a newborn screening test for the presence of | 6 | | metachromatic leukodystrophy, as required under the Newborn | 7 | | Metabolic Screening Act, at a rate not less than the fee | 8 | | charged by the Department of Public Health. Notwithstanding | 9 | | any other provision of this Code, the medical assistance | 10 | | program shall, subject to appropriation and federal approval, | 11 | | also reimburse hospitals for costs associated with all newborn | 12 | | screening tests added on and after the effective date of this | 13 | | amendatory Act of the 103rd General Assembly to the Newborn | 14 | | Metabolic Screening Act and required to be performed under | 15 | | that Act at a rate not less than the fee charged by the | 16 | | Department of Public Health. The Department shall seek federal | 17 | | approval before the implementation of the newborn screening | 18 | | test fees by the Department of Public Health. | 19 | | Notwithstanding any other provision of this Code, | 20 | | beginning on January 1, 2024, subject to federal approval, | 21 | | cognitive assessment and care planning services provided to a | 22 | | person who experiences signs or symptoms of cognitive | 23 | | impairment, as defined by the Diagnostic and Statistical | 24 | | Manual of Mental Disorders, Fifth Edition, shall be covered | 25 | | under the medical assistance program for persons who are | 26 | | otherwise eligible for medical assistance under this Article. |
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| 1 | | Notwithstanding any other provision of this Code, | 2 | | medically necessary reconstructive services that are intended | 3 | | to restore physical appearance shall be covered under the | 4 | | medical assistance program for persons who are otherwise | 5 | | eligible for medical assistance under this Article. As used in | 6 | | this paragraph, "reconstructive services" means treatments | 7 | | performed on structures of the body damaged by trauma to | 8 | | restore physical appearance. | 9 | | (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; | 10 | | 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article | 11 | | 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, | 12 | | eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; | 13 | | 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. | 14 | | 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; | 15 | | 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. | 16 | | 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; | 17 | | 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. | 18 | | 1-1-24; revised 12-15-23.) | 19 | | Section 5. The Newborn Metabolic Screening Act is amended | 20 | | by adding Section 3.6 as follows: | 21 | | (410 ILCS 240/3.6 new) | 22 | | Sec. 3.6. Duchenne muscular dystrophy. | 23 | | (a) Subject to appropriation, the Department shall provide | 24 | | all newborns with screening tests for the presence of Duchenne |
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| 1 | | muscular dystrophy. The testing shall begin within 6 months | 2 | | after the occurrence of all of the following milestones: | 3 | | (1) Unless the federal Food and Drug Administration | 4 | | approves a screening test for Duchenne muscular dystrophy | 5 | | using dried blood spots, the development and validation of | 6 | | a reliable methodology for screening newborns for Duchenne | 7 | | muscular dystrophy using dried blood spots and a | 8 | | methodology for conducting quality assurance testing of | 9 | | the screening test. | 10 | | (2) The availability of any necessary reagent for a | 11 | | Duchenne muscular dystrophy screening test. | 12 | | (3) The establishment and verification of relevant and | 13 | | appropriate performance specifications as defined under | 14 | | the federal Clinical Laboratory Improvement Amendments and | 15 | | regulations thereunder for Federal Drug | 16 | | Administration-cleared or in-house developed methods, | 17 | | performed under an institutional review board approved | 18 | | protocol, if required. | 19 | | (4) The availability of quality assurance testing and | 20 | | comparative threshold values for Duchenne muscular | 21 | | dystrophy screening tests. | 22 | | (5) The acquisition and installation by the Department | 23 | | of equipment necessary to implement Duchenne muscular | 24 | | dystrophy screening tests. | 25 | | (6) The establishment of precise threshold values | 26 | | ensuring defined disorder identification of Duchenne |
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| 1 | | muscular dystrophy. | 2 | | (7) The authentication of pilot testing indicating | 3 | | that each milestone described in paragraphs (1) through | 4 | | (6) has been achieved. | 5 | | (8) The authentication of achieving the potential of | 6 | | high throughput standards for statewide volume of each | 7 | | Duchenne muscular dystrophy screening test concomitant | 8 | | with each milestone described in paragraphs (1) through | 9 | | (4). | 10 | | (b) To accumulate the resources for the costs, including | 11 | | start-up costs, associated with Duchenne muscular dystrophy | 12 | | screening tests and any follow-up programs, the Department may | 13 | | require payment of an additional fee for administering a | 14 | | Duchenne muscular dystrophy screening test under this Section. | 15 | | The Department may not require the payment of the additional | 16 | | fee prior to 6 months before the Department administers | 17 | | Duchenne muscular dystrophy screening tests under this | 18 | | Section. | 19 | | Section 99. Effective date. This Act takes effect upon | 20 | | becoming law. |
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