Illinois General Assembly - Full Text of HB2537
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Full Text of HB2537  99th General Assembly




State of Illinois
2015 and 2016


Introduced 2/18/2015, by Rep. Michael W. Tryon


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to provide medical assistance coverage for diabetes education provided by a certified diabetes education provider for children with Type 1 diabetes who are under the age of 18. Defines "certified diabetes education provider" to mean a professional who has undergone training and certification under conditions approved by the American Association of Diabetes Educators or a successor association of professionals. Defines "Type 1 diabetes" to have the same meaning ascribed to it by the American Diabetes Association or any successor association. Effective immediately.

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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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



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1laws of this State, but not including abortions, or induced
2miscarriages or premature births, unless, in the opinion of a
3physician, such procedures are necessary for the preservation
4of the life of the woman seeking such treatment, or except an
5induced premature birth intended to produce a live viable child
6and such procedure is necessary for the health of the mother or
7her unborn child. The Illinois Department, by rule, shall
8prohibit any physician from providing medical assistance to
9anyone eligible therefor under this Code where such physician
10has been found guilty of performing an abortion procedure in a
11wilful and wanton manner upon a woman who was not pregnant at
12the time such abortion procedure was performed. The term "any
13other type of remedial care" shall include nursing care and
14nursing home service for persons who rely on treatment by
15spiritual means alone through prayer for healing.
16    Notwithstanding any other provision of this Section, a
17comprehensive tobacco use cessation program that includes
18purchasing prescription drugs or prescription medical devices
19approved by the Food and Drug Administration shall be covered
20under the medical assistance program under this Article for
21persons who are otherwise eligible for assistance under this
23    Notwithstanding any other provision of this Code, the
24Illinois Department may not require, as a condition of payment
25for any laboratory test authorized under this Article, that a
26physician's handwritten signature appear on the laboratory



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1test order form. The Illinois Department may, however, impose
2other appropriate requirements regarding laboratory test order
4    Notwithstanding any other provision of this Code, the
5Department shall provide medical assistance coverage for
6diabetes education provided by a certified diabetes education
7provider for children with Type 1 diabetes who are under the
8age of 18. For purposes of this paragraph:
9        "Certified diabetes education provider" means a
10    professional who has undergone training and certification
11    under conditions approved by the American Association of
12    Diabetes Educators or a successor association of
13    professionals.
14        "Type 1 diabetes" shall have the same meaning ascribed
15    to it by the American Diabetes Association or any successor
16    association.
17    Upon receipt of federal approval of an amendment to the
18Illinois Title XIX State Plan for this purpose, the Department
19shall authorize the Chicago Public Schools (CPS) to procure a
20vendor or vendors to manufacture eyeglasses for individuals
21enrolled in a school within the CPS system. CPS shall ensure
22that its vendor or vendors are enrolled as providers in the
23medical assistance program and in any capitated Medicaid
24managed care entity (MCE) serving individuals enrolled in a
25school within the CPS system. Under any contract procured under
26this provision, the vendor or vendors must serve only



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



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1health clinic or Federally Qualified Health Center or other
2enrolled provider, as determined by the Department, through
3which dental services covered under this Section are performed.
4The Department shall establish a process for payment of claims
5for reimbursement for covered dental services rendered under
6this provision.
7    The Illinois Department, by rule, may distinguish and
8classify the medical services to be provided only in accordance
9with the classes of persons designated in Section 5-2.
10    The Department of Healthcare and Family Services must
11provide coverage and reimbursement for amino acid-based
12elemental formulas, regardless of delivery method, for the
13diagnosis and treatment of (i) eosinophilic disorders and (ii)
14short bowel syndrome when the prescribing physician has issued
15a written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for women
2035 years of age or older who are eligible for medical
21assistance under this Article, as follows:
22        (A) A baseline mammogram for women 35 to 39 years of
23    age.
24        (B) An annual mammogram for women 40 years of age or
25    older.
26        (C) A mammogram at the age and intervals considered



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1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (D) A comprehensive ultrasound screening of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue, when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10    All screenings shall include a physical breast exam,
11instruction on self-examination and information regarding the
12frequency of self-examination and its value as a preventative
13tool. For purposes of this Section, "low-dose mammography"
14means the x-ray examination of the breast using equipment
15dedicated specifically for mammography, including the x-ray
16tube, filter, compression device, and image receptor, with an
17average radiation exposure delivery of less than one rad per
18breast for 2 views of an average size breast. The term also
19includes digital mammography.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography



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1facilities, and doctors, including radiologists, to establish
2quality standards.
3    Subject to federal approval, the Department shall
4establish a rate methodology for mammography at federally
5qualified health centers and other encounter-rate clinics.
6These clinics or centers may also collaborate with other
7hospital-based mammography facilities.
8    The Department shall establish a methodology to remind
9women who are age-appropriate for screening mammography, but
10who have not received a mammogram within the previous 18
11months, of the importance and benefit of screening mammography.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. An evaluation of the
25pilot program shall be carried out measuring health outcomes
26and cost of care for those served by the pilot program compared



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1to similarly situated patients who are not served by the pilot
3    Any medical or health care provider shall immediately
4recommend, to any pregnant woman who is being provided prenatal
5services and is suspected of drug abuse or is addicted as
6defined in the Alcoholism and Other Drug Abuse and Dependency
7Act, referral to a local substance abuse treatment provider
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department of
14Human Services.
15    All medical providers providing medical assistance to
16pregnant women under this Code shall receive information from
17the Department on the availability of services under the Drug
18Free Families with a Future or any comparable program providing
19case management services for addicted women, including
20information on appropriate referrals for other social services
21that may be needed by addicted women in addition to treatment
22for addiction.
23    The Illinois Department, in cooperation with the
24Departments of Human Services (as successor to the Department
25of Alcoholism and Substance Abuse) and Public Health, through a
26public awareness campaign, may provide information concerning



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1treatment for alcoholism and drug abuse and addiction, prenatal
2health care, and other pertinent programs directed at reducing
3the number of drug-affected infants born to recipients of
4medical assistance.
5    Neither the Department of Healthcare and Family Services
6nor the Department of Human Services shall sanction the
7recipient solely on the basis of her substance abuse.
8    The Illinois Department shall establish such regulations
9governing the dispensing of health services under this Article
10as it shall deem appropriate. The Department should seek the
11advice of formal professional advisory committees appointed by
12the Director of the Illinois Department for the purpose of
13providing regular advice on policy and administrative matters,
14information dissemination and educational activities for
15medical and health care providers, and consistency in
16procedures to the Illinois Department.
17    The Illinois Department may develop and contract with
18Partnerships of medical providers to arrange medical services
19for persons eligible under Section 5-2 of this Code.
20Implementation of this Section may be by demonstration projects
21in certain geographic areas. The Partnership shall be
22represented by a sponsor organization. The Department, by rule,
23shall develop qualifications for sponsors of Partnerships.
24Nothing in this Section shall be construed to require that the
25sponsor organization be a medical organization.
26    The sponsor must negotiate formal written contracts with



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1medical providers for physician services, inpatient and
2outpatient hospital care, home health services, treatment for
3alcoholism and substance abuse, and other services determined
4necessary by the Illinois Department by rule for delivery by
5Partnerships. Physician services must include prenatal and
6obstetrical care. The Illinois Department shall reimburse
7medical services delivered by Partnership providers to clients
8in target areas according to provisions of this Article and the
9Illinois Health Finance Reform Act, except that:
10        (1) Physicians participating in a Partnership and
11    providing certain services, which shall be determined by
12    the Illinois Department, to persons in areas covered by the
13    Partnership may receive an additional surcharge for such
14    services.
15        (2) The Department may elect to consider and negotiate
16    financial incentives to encourage the development of
17    Partnerships and the efficient delivery of medical care.
18        (3) Persons receiving medical services through
19    Partnerships may receive medical and case management
20    services above the level usually offered through the
21    medical assistance program.
22    Medical providers shall be required to meet certain
23qualifications to participate in Partnerships to ensure the
24delivery of high quality medical services. These
25qualifications shall be determined by rule of the Illinois
26Department and may be higher than qualifications for



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1participation in the medical assistance program. Partnership
2sponsors may prescribe reasonable additional qualifications
3for participation by medical providers, only with the prior
4written approval of the Illinois Department.
5    Nothing in this Section shall limit the free choice of
6practitioners, hospitals, and other providers of medical
7services by clients. In order to ensure patient freedom of
8choice, the Illinois Department shall immediately promulgate
9all rules and take all other necessary actions so that provided
10services may be accessed from therapeutically certified
11optometrists to the full extent of the Illinois Optometric
12Practice Act of 1987 without discriminating between service
14    The Department shall apply for a waiver from the United
15States Health Care Financing Administration to allow for the
16implementation of Partnerships under this Section.
17    The Illinois Department shall require health care
18providers to maintain records that document the medical care
19and services provided to recipients of Medical Assistance under
20this Article. Such records must be retained for a period of not
21less than 6 years from the date of service or as provided by
22applicable State law, whichever period is longer, except that
23if an audit is initiated within the required retention period
24then the records must be retained until the audit is completed
25and every exception is resolved. The Illinois Department shall
26require health care providers to make available, when



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1authorized by the patient, in writing, the medical records in a
2timely fashion to other health care providers who are treating
3or serving persons eligible for Medical Assistance under this
4Article. All dispensers of medical services shall be required
5to maintain and retain business and professional records
6sufficient to fully and accurately document the nature, scope,
7details and receipt of the health care provided to persons
8eligible for medical assistance under this Code, in accordance
9with regulations promulgated by the Illinois Department. The
10rules and regulations shall require that proof of the receipt
11of prescription drugs, dentures, prosthetic devices and
12eyeglasses by eligible persons under this Section accompany
13each claim for reimbursement submitted by the dispenser of such
14medical services. No such claims for reimbursement shall be
15approved for payment by the Illinois Department without such
16proof of receipt, unless the Illinois Department shall have put
17into effect and shall be operating a system of post-payment
18audit and review which shall, on a sampling basis, be deemed
19adequate by the Illinois Department to assure that such drugs,
20dentures, prosthetic devices and eyeglasses for which payment
21is being made are actually being received by eligible
22recipients. Within 90 days after the effective date of this
23amendatory Act of 1984, the Illinois Department shall establish
24a current list of acquisition costs for all prosthetic devices
25and any other items recognized as medical equipment and
26supplies reimbursable under this Article and shall update such



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1list on a quarterly basis, except that the acquisition costs of
2all prescription drugs shall be updated no less frequently than
3every 30 days as required by Section 5-5.12.
4    The rules and regulations of the Illinois Department shall
5require that a written statement including the required opinion
6of a physician shall accompany any claim for reimbursement for
7abortions, or induced miscarriages or premature births. This
8statement shall indicate what procedures were used in providing
9such medical services.
10    Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after July 22, 2013, (the
12effective date of Public Act 98-104), establish procedures to
13permit skilled care facilities licensed under the Nursing Home
14Care Act to submit monthly billing claims for reimbursement
15purposes. Following development of these procedures, the
16Department shall have an additional 365 days to test the
17viability of the new system and to ensure that any necessary
18operational or structural changes to its information
19technology platforms are implemented.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after August 15, 2014 (the
22effective date of Public Act 98-963) this amendatory Act of the
2398th General Assembly, establish procedures to permit ID/DD
24facilities licensed under the ID/DD Community Care Act to
25submit monthly billing claims for reimbursement purposes.
26Following development of these procedures, the Department



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1shall have an additional 365 days to test the viability of the
2new system and to ensure that any necessary operational or
3structural changes to its information technology platforms are
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.



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1Unless otherwise specified, such termination of eligibility or
2disenrollment is not subject to the Department's hearing
3process. However, a disenrolled vendor may reapply without
5    The Department has the discretion to limit the conditional
6enrollment period for vendors based upon category of risk of
7the vendor.
8    Prior to enrollment and during the conditional enrollment
9period in the medical assistance program, all vendors shall be
10subject to enhanced oversight, screening, and review based on
11the risk of fraud, waste, and abuse that is posed by the
12category of risk of the vendor. The Illinois Department shall
13establish the procedures for oversight, screening, and review,
14which may include, but need not be limited to: criminal and
15financial background checks; fingerprinting; license,
16certification, and authorization verifications; unscheduled or
17unannounced site visits; database checks; prepayment audit
18reviews; audits; payment caps; payment suspensions; and other
19screening as required by federal or State law.
20    The Department shall define or specify the following: (i)
21by provider notice, the "category of risk of the vendor" for
22each type of vendor, which shall take into account the level of
23screening applicable to a particular category of vendor under
24federal law and regulations; (ii) by rule or provider notice,
25the maximum length of the conditional enrollment period for
26each category of risk of the vendor; and (iii) by rule, the



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1hearing rights, if any, afforded to a vendor in each category
2of risk of the vendor that is terminated or disenrolled during
3the conditional enrollment period.
4    To be eligible for payment consideration, a vendor's
5payment claim or bill, either as an initial claim or as a
6resubmitted claim following prior rejection, must be received
7by the Illinois Department, or its fiscal intermediary, no
8later than 180 days after the latest date on the claim on which
9medical goods or services were provided, with the following
11        (1) In the case of a provider whose enrollment is in
12    process by the Illinois Department, the 180-day period
13    shall not begin until the date on the written notice from
14    the Illinois Department that the provider enrollment is
15    complete.
16        (2) In the case of errors attributable to the Illinois
17    Department or any of its claims processing intermediaries
18    which result in an inability to receive, process, or
19    adjudicate a claim, the 180-day period shall not begin
20    until the provider has been notified of the error.
21        (3) In the case of a provider for whom the Illinois
22    Department initiates the monthly billing process.
23        (4) In the case of a provider operated by a unit of
24    local government with a population exceeding 3,000,000
25    when local government funds finance federal participation
26    for claims payments.



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1    For claims for services rendered during a period for which
2a recipient received retroactive eligibility, claims must be
3filed within 180 days after the Department determines the
4applicant is eligible. For claims for which the Illinois
5Department is not the primary payer, claims must be submitted
6to the Illinois Department within 180 days after the final
7adjudication by the primary payer.
8    In the case of long term care facilities, within 5 days of
9receipt by the facility of required prescreening information,
10data for new admissions shall be entered into the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or successor system, and
13within 15 days of receipt by the facility of required
14prescreening information, admission documents shall be
15submitted through MEDI or REV or shall be submitted directly to
16the Department of Human Services using required admission
17forms. Effective September 1, 2014, admission documents,
18including all prescreening information, must be submitted
19through MEDI or REV. Confirmation numbers assigned to an
20accepted transaction shall be retained by a facility to verify
21timely submittal. Once an admission transaction has been
22completed, all resubmitted claims following prior rejection
23are subject to receipt no later than 180 days after the
24admission transaction has been completed.
25    Claims that are not submitted and received in compliance
26with the foregoing requirements shall not be eligible for



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1payment under the medical assistance program, and the State
2shall have no liability for payment of those claims.
3    To the extent consistent with applicable information and
4privacy, security, and disclosure laws, State and federal
5agencies and departments shall provide the Illinois Department
6access to confidential and other information and data necessary
7to perform eligibility and payment verifications and other
8Illinois Department functions. This includes, but is not
9limited to: information pertaining to licensure;
10certification; earnings; immigration status; citizenship; wage
11reporting; unearned and earned income; pension income;
12employment; supplemental security income; social security
13numbers; National Provider Identifier (NPI) numbers; the
14National Practitioner Data Bank (NPDB); program and agency
15exclusions; taxpayer identification numbers; tax delinquency;
16corporate information; and death records.
17    The Illinois Department shall enter into agreements with
18State agencies and departments, and is authorized to enter into
19agreements with federal agencies and departments, under which
20such agencies and departments shall share data necessary for
21medical assistance program integrity functions and oversight.
22The Illinois Department shall develop, in cooperation with
23other State departments and agencies, and in compliance with
24applicable federal laws and regulations, appropriate and
25effective methods to share such data. At a minimum, and to the
26extent necessary to provide data sharing, the Illinois



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1Department shall enter into agreements with State agencies and
2departments, and is authorized to enter into agreements with
3federal agencies and departments, including but not limited to:
4the Secretary of State; the Department of Revenue; the
5Department of Public Health; the Department of Human Services;
6and the Department of Financial and Professional Regulation.
7    Beginning in fiscal year 2013, the Illinois Department
8shall set forth a request for information to identify the
9benefits of a pre-payment, post-adjudication, and post-edit
10claims system with the goals of streamlining claims processing
11and provider reimbursement, reducing the number of pending or
12rejected claims, and helping to ensure a more transparent
13adjudication process through the utilization of: (i) provider
14data verification and provider screening technology; and (ii)
15clinical code editing; and (iii) pre-pay, pre- or
16post-adjudicated predictive modeling with an integrated case
17management system with link analysis. Such a request for
18information shall not be considered as a request for proposal
19or as an obligation on the part of the Illinois Department to
20take any action or acquire any products or services.
21    The Illinois Department shall establish policies,
22procedures, standards and criteria by rule for the acquisition,
23repair and replacement of orthotic and prosthetic devices and
24durable medical equipment. Such rules shall provide, but not be
25limited to, the following services: (1) immediate repair or
26replacement of such devices by recipients; and (2) rental,



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1lease, purchase or lease-purchase of durable medical equipment
2in a cost-effective manner, taking into consideration the
3recipient's medical prognosis, the extent of the recipient's
4needs, and the requirements and costs for maintaining such
5equipment. Subject to prior approval, such rules shall enable a
6recipient to temporarily acquire and use alternative or
7substitute devices or equipment pending repairs or
8replacements of any device or equipment previously authorized
9for such recipient by the Department.
10    The Department shall execute, relative to the nursing home
11prescreening project, written inter-agency agreements with the
12Department of Human Services and the Department on Aging, to
13effect the following: (i) intake procedures and common
14eligibility criteria for those persons who are receiving
15non-institutional services; and (ii) the establishment and
16development of non-institutional services in areas of the State
17where they are not currently available or are undeveloped; and
18(iii) notwithstanding any other provision of law, subject to
19federal approval, on and after July 1, 2012, an increase in the
20determination of need (DON) scores from 29 to 37 for applicants
21for institutional and home and community-based long term care;
22if and only if federal approval is not granted, the Department
23may, in conjunction with other affected agencies, implement
24utilization controls or changes in benefit packages to
25effectuate a similar savings amount for this population; and
26(iv) no later than July 1, 2013, minimum level of care



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1eligibility criteria for institutional and home and
2community-based long term care; and (v) no later than October
31, 2013, establish procedures to permit long term care
4providers access to eligibility scores for individuals with an
5admission date who are seeking or receiving services from the
6long term care provider. In order to select the minimum level
7of care eligibility criteria, the Governor shall establish a
8workgroup that includes affected agency representatives and
9stakeholders representing the institutional and home and
10community-based long term care interests. This Section shall
11not restrict the Department from implementing lower level of
12care eligibility criteria for community-based services in
13circumstances where federal approval has been granted.
14    The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation and
18programs for monitoring of utilization of health care services
19and facilities, as it affects persons eligible for medical
20assistance under this Code.
21    The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24        (a) actual statistics and trends in utilization of
25    medical services by public aid recipients;
26        (b) actual statistics and trends in the provision of



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



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1any methodologies authorized by this Code to reduce any rate of
2reimbursement for services or other payments in accordance with
3Section 5-5e.
4    Because kidney transplantation can be an appropriate, cost
5effective alternative to renal dialysis when medically
6necessary and notwithstanding the provisions of Section 1-11 of
7this Code, beginning October 1, 2014, the Department shall
8cover kidney transplantation for noncitizens with end-stage
9renal disease who are not eligible for comprehensive medical
10benefits, who meet the residency requirements of Section 5-3 of
11this Code, and who would otherwise meet the financial
12requirements of the appropriate class of eligible persons under
13Section 5-2 of this Code. To qualify for coverage of kidney
14transplantation, such person must be receiving emergency renal
15dialysis services covered by the Department. Providers under
16this Section shall be prior approved and certified by the
17Department to perform kidney transplantation and the services
18under this Section shall be limited to services associated with
19kidney transplantation.
20(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
21eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
229-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
237-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
24eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
25revised 10-2-14.)
26    Section 99. Effective date. This Act takes effect upon



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1becoming law.