Illinois General Assembly - Full Text of HB4013
Illinois General Assembly

Previous General Assemblies

Full Text of HB4013  99th General Assembly




HB4013 EngrossedLRB099 04328 KTG 24355 b

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 State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit, on
18or after July 1, 1980, the non-contributory portion of any such
19program to include the expenses of obtaining an abortion,
20induced miscarriage or induced premature birth unless, in the
21opinion of a physician, such procedures are necessary for the
22preservation of the life of the woman seeking such treatment,
23or except an induced premature birth intended to produce a live



HB4013 Engrossed- 2 -LRB099 04328 KTG 24355 b

1viable child and such procedure is necessary for the health of
2the mother or the unborn child. The program may also include
3coverage for those who rely on treatment by prayer or spiritual
4means alone for healing in accordance with the tenets and
5practice of a recognized religious denomination.
6    The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits and
11as optional benefits, the medical services of practitioners in
12all categories licensed under the Medical Practice Act of 1987,
13(3) to include reasonable controls, which may include
14deductible and co-insurance provisions, applicable to some or
15all of the benefits, or a coordination of benefits provision,
16to prevent or minimize unnecessary utilization of the various
17hospital, surgical and medical expenses to be provided and to
18provide reasonable assurance of stability of the program, and
19(4) to provide benefits to the extent possible to members
20throughout the State, wherever located, on an equitable basis.
21Notwithstanding any other provision of this Section or Act, for
22all members or dependents who are eligible for benefits under
23Social Security or the Railroad Retirement system or who had
24sufficient Medicare-covered government employment, the
25Department shall reduce benefits which would otherwise be paid
26by Medicare, by the amount of benefits for which the member or



HB4013 Engrossed- 3 -LRB099 04328 KTG 24355 b

1dependents are eligible under Medicare, except that such
2reduction in benefits shall apply only to those members or
3dependents who (1) first become eligible for such medicare
4coverage on or after the effective date of this amendatory Act
5of 1992; or (2) are Medicare-eligible members or dependents of
6a local government unit which began participation in the
7program on or after July 1, 1992; or (3) remain eligible for
8but no longer receive Medicare coverage which they had been
9receiving on or after the effective date of this amendatory Act
10of 1992.
11    Notwithstanding any other provisions of this Act, where a
12covered member or dependents are eligible for benefits under
13the federal Medicare health insurance program (Title XVIII of
14the Social Security Act as added by Public Law 89-97, 89th
15Congress), benefits paid under the State of Illinois program or
16plan will be reduced by the amount of benefits paid by
17Medicare. For members or dependents who are eligible for
18benefits under Social Security or the Railroad Retirement
19system or who had sufficient Medicare-covered government
20employment, benefits shall be reduced by the amount for which
21the member or dependent is eligible under Medicare, except that
22such reduction in benefits shall apply only to those members or
23dependents who (1) first become eligible for such Medicare
24coverage on or after the effective date of this amendatory Act
25of 1992; or (2) are Medicare-eligible members or dependents of
26a local government unit which began participation in the



HB4013 Engrossed- 4 -LRB099 04328 KTG 24355 b

1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 93-47, eff. 7-1-03.)
17    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
18    Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.



HB4013 Engrossed- 5 -LRB099 04328 KTG 24355 b

1    However, nothing in this Act shall be construed to permit,
2after the effective date of this amendatory Act of 1983, the
3noncontributory portion of any such program to include the
4expenses of obtaining an abortion, induced miscarriage or
5induced premature birth unless, in the opinion of a physician,
6such procedures are necessary for the preservation of the life
7of the woman seeking such treatment, or except an induced
8premature birth intended to produce a live viable child and
9such procedure is necessary for the health of the mother or her
10unborn child.
11(Source: P.A. 85-848.)
12    Section 10. The Illinois Public Aid Code is amended by
13changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
14    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
15    Sec. 5-5. Medical services. The Illinois Department, by
16rule, shall determine the quantity and quality of and the rate
17of reimbursement for the medical assistance for which payment
18will be authorized, and the medical services to be provided,
19which may include all or part of the following: (1) inpatient
20hospital services; (2) outpatient hospital services; (3) other
21laboratory and X-ray services; (4) skilled nursing home
22services; (5) physicians' services whether furnished in the
23office, the patient's home, a hospital, a skilled nursing home,
24or elsewhere; (6) medical care, or any other type of remedial



HB4013 Engrossed- 6 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 7 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 8 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 9 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 10 -LRB099 04328 KTG 24355 b

1    The Illinois Department, by rule, may distinguish and
2classify the medical services to be provided only in accordance
3with the classes of persons designated in Section 5-2.
4    The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11    The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for women
1435 years of age or older who are eligible for medical
15assistance under this Article, as follows:
16        (A) A baseline mammogram for women 35 to 39 years of
17    age.
18        (B) An annual mammogram for women 40 years of age or
19    older.
20        (C) A mammogram at the age and intervals considered
21    medically necessary by the woman's health care provider for
22    women under 40 years of age and having a family history of
23    breast cancer, prior personal history of breast cancer,
24    positive genetic testing, or other risk factors.
25        (D) A comprehensive ultrasound screening of an entire
26    breast or breasts if a mammogram demonstrates



HB4013 Engrossed- 11 -LRB099 04328 KTG 24355 b

1    heterogeneous or dense breast tissue, when medically
2    necessary as determined by a physician licensed to practice
3    medicine in all of its branches.
4    All screenings shall include a physical breast exam,
5instruction on self-examination and information regarding the
6frequency of self-examination and its value as a preventative
7tool. For purposes of this Section, "low-dose mammography"
8means the x-ray examination of the breast using equipment
9dedicated specifically for mammography, including the x-ray
10tube, filter, compression device, and image receptor, with an
11average radiation exposure delivery of less than one rad per
12breast for 2 views of an average size breast. The term also
13includes digital mammography.
14    On and after January 1, 2012, providers participating in a
15quality improvement program approved by the Department shall be
16reimbursed for screening and diagnostic mammography at the same
17rate as the Medicare program's rates, including the increased
18reimbursement for digital mammography.
19    The Department shall convene an expert panel including
20representatives of hospitals, free-standing mammography
21facilities, and doctors, including radiologists, to establish
22quality standards.
23    Subject to federal approval, the Department shall
24establish a rate methodology for mammography at federally
25qualified health centers and other encounter-rate clinics.
26These clinics or centers may also collaborate with other



HB4013 Engrossed- 12 -LRB099 04328 KTG 24355 b

1hospital-based mammography facilities.
2    The Department shall establish a methodology to remind
3women who are age-appropriate for screening mammography, but
4who have not received a mammogram within the previous 18
5months, of the importance and benefit of screening mammography.
6    The Department shall establish a performance goal for
7primary care providers with respect to their female patients
8over age 40 receiving an annual mammogram. This performance
9goal shall be used to provide additional reimbursement in the
10form of a quality performance bonus to primary care providers
11who meet that goal.
12    The Department shall devise a means of case-managing or
13patient navigation for beneficiaries diagnosed with breast
14cancer. This program shall initially operate as a pilot program
15in areas of the State with the highest incidence of mortality
16related to breast cancer. At least one pilot program site shall
17be in the metropolitan Chicago area and at least one site shall
18be outside the metropolitan Chicago area. An evaluation of the
19pilot program shall be carried out measuring health outcomes
20and cost of care for those served by the pilot program compared
21to similarly situated patients who are not served by the pilot
23    Any medical or health care provider shall immediately
24recommend, to any pregnant woman who is being provided prenatal
25services and is suspected of drug abuse or is addicted as
26defined in the Alcoholism and Other Drug Abuse and Dependency



HB4013 Engrossed- 13 -LRB099 04328 KTG 24355 b

1Act, referral to a local substance abuse treatment provider
2licensed by the Department of Human Services or to a licensed
3hospital which provides substance abuse treatment services.
4The Department of Healthcare and Family Services shall assure
5coverage for the cost of treatment of the drug abuse or
6addiction for pregnant recipients in accordance with the
7Illinois Medicaid Program in conjunction with the Department of
8Human Services.
9    All medical providers providing medical assistance to
10pregnant women under this Code shall receive information from
11the Department on the availability of services under the Drug
12Free Families with a Future or any comparable program providing
13case management services for addicted women, including
14information on appropriate referrals for other social services
15that may be needed by addicted women in addition to treatment
16for addiction.
17    The Illinois Department, in cooperation with the
18Departments of Human Services (as successor to the Department
19of Alcoholism and Substance Abuse) and Public Health, through a
20public awareness campaign, may provide information concerning
21treatment for alcoholism and drug abuse and addiction, prenatal
22health care, and other pertinent programs directed at reducing
23the number of drug-affected infants born to recipients of
24medical assistance.
25    Neither the Department of Healthcare and Family Services
26nor the Department of Human Services shall sanction the



HB4013 Engrossed- 14 -LRB099 04328 KTG 24355 b

1recipient solely on the basis of her substance abuse.
2    The Illinois Department shall establish such regulations
3governing the dispensing of health services under this Article
4as it shall deem appropriate. The Department should seek the
5advice of formal professional advisory committees appointed by
6the Director of the Illinois Department for the purpose of
7providing regular advice on policy and administrative matters,
8information dissemination and educational activities for
9medical and health care providers, and consistency in
10procedures to the Illinois Department.
11    The Illinois Department may develop and contract with
12Partnerships of medical providers to arrange medical services
13for persons eligible under Section 5-2 of this Code.
14Implementation of this Section may be by demonstration projects
15in certain geographic areas. The Partnership shall be
16represented by a sponsor organization. The Department, by rule,
17shall develop qualifications for sponsors of Partnerships.
18Nothing in this Section shall be construed to require that the
19sponsor organization be a medical organization.
20    The sponsor must negotiate formal written contracts with
21medical providers for physician services, inpatient and
22outpatient hospital care, home health services, treatment for
23alcoholism and substance abuse, and other services determined
24necessary by the Illinois Department by rule for delivery by
25Partnerships. Physician services must include prenatal and
26obstetrical care. The Illinois Department shall reimburse



HB4013 Engrossed- 15 -LRB099 04328 KTG 24355 b

1medical services delivered by Partnership providers to clients
2in target areas according to provisions of this Article and the
3Illinois Health Finance Reform Act, except that:
4        (1) Physicians participating in a Partnership and
5    providing certain services, which shall be determined by
6    the Illinois Department, to persons in areas covered by the
7    Partnership may receive an additional surcharge for such
8    services.
9        (2) The Department may elect to consider and negotiate
10    financial incentives to encourage the development of
11    Partnerships and the efficient delivery of medical care.
12        (3) Persons receiving medical services through
13    Partnerships may receive medical and case management
14    services above the level usually offered through the
15    medical assistance program.
16    Medical providers shall be required to meet certain
17qualifications to participate in Partnerships to ensure the
18delivery of high quality medical services. These
19qualifications shall be determined by rule of the Illinois
20Department and may be higher than qualifications for
21participation in the medical assistance program. Partnership
22sponsors may prescribe reasonable additional qualifications
23for participation by medical providers, only with the prior
24written approval of the Illinois Department.
25    Nothing in this Section shall limit the free choice of
26practitioners, hospitals, and other providers of medical



HB4013 Engrossed- 16 -LRB099 04328 KTG 24355 b

1services by clients. In order to ensure patient freedom of
2choice, the Illinois Department shall immediately promulgate
3all rules and take all other necessary actions so that provided
4services may be accessed from therapeutically certified
5optometrists to the full extent of the Illinois Optometric
6Practice Act of 1987 without discriminating between service
8    The Department shall apply for a waiver from the United
9States Health Care Financing Administration to allow for the
10implementation of Partnerships under this Section.
11    The Illinois Department shall require health care
12providers to maintain records that document the medical care
13and services provided to recipients of Medical Assistance under
14this Article. Such records must be retained for a period of not
15less than 6 years from the date of service or as provided by
16applicable State law, whichever period is longer, except that
17if an audit is initiated within the required retention period
18then the records must be retained until the audit is completed
19and every exception is resolved. The Illinois Department shall
20require health care providers to make available, when
21authorized by the patient, in writing, the medical records in a
22timely fashion to other health care providers who are treating
23or serving persons eligible for Medical Assistance under this
24Article. All dispensers of medical services shall be required
25to maintain and retain business and professional records
26sufficient to fully and accurately document the nature, scope,



HB4013 Engrossed- 17 -LRB099 04328 KTG 24355 b

1details and receipt of the health care provided to persons
2eligible for medical assistance under this Code, in accordance
3with regulations promulgated by the Illinois Department. The
4rules and regulations shall require that proof of the receipt
5of prescription drugs, dentures, prosthetic devices and
6eyeglasses by eligible persons under this Section accompany
7each claim for reimbursement submitted by the dispenser of such
8medical services. No such claims for reimbursement shall be
9approved for payment by the Illinois Department without such
10proof of receipt, unless the Illinois Department shall have put
11into effect and shall be operating a system of post-payment
12audit and review which shall, on a sampling basis, be deemed
13adequate by the Illinois Department to assure that such drugs,
14dentures, prosthetic devices and eyeglasses for which payment
15is being made are actually being received by eligible
16recipients. Within 90 days after the effective date of this
17amendatory Act of 1984, the Illinois Department shall establish
18a current list of acquisition costs for all prosthetic devices
19and any other items recognized as medical equipment and
20supplies reimbursable under this Article and shall update such
21list on a quarterly basis, except that the acquisition costs of
22all prescription drugs shall be updated no less frequently than
23every 30 days as required by Section 5-5.12.
24    The rules and regulations of the Illinois Department shall
25require that a written statement including the required opinion
26of a physician shall accompany any claim for reimbursement for



HB4013 Engrossed- 18 -LRB099 04328 KTG 24355 b

1abortions, or induced miscarriages or premature births. This
2statement shall indicate what procedures were used in providing
3such medical services.
4    Notwithstanding any other law to the contrary, the Illinois
5Department shall, within 365 days after July 22, 2013, (the
6effective date of Public Act 98-104), establish procedures to
7permit skilled care facilities licensed under the Nursing Home
8Care Act to submit monthly billing claims for reimbursement
9purposes. Following development of these procedures, the
10Department shall have an additional 365 days to test the
11viability of the new system and to ensure that any necessary
12operational or structural changes to its information
13technology platforms are implemented.
14    Notwithstanding any other law to the contrary, the Illinois
15Department shall, within 365 days after August 15, 2014 (the
16effective date of Public Act 98-963) this amendatory Act of the
1798th General Assembly, establish procedures to permit ID/DD
18facilities licensed under the ID/DD Community Care Act to
19submit monthly billing claims for reimbursement purposes.
20Following development of these procedures, the Department
21shall have an additional 365 days to test the viability of the
22new system and to ensure that any necessary operational or
23structural changes to its information technology platforms are
25    The Illinois Department shall require all dispensers of
26medical services, other than an individual practitioner or



HB4013 Engrossed- 19 -LRB099 04328 KTG 24355 b

1group of practitioners, desiring to participate in the Medical
2Assistance program established under this Article to disclose
3all financial, beneficial, ownership, equity, surety or other
4interests in any and all firms, corporations, partnerships,
5associations, business enterprises, joint ventures, agencies,
6institutions or other legal entities providing any form of
7health care services in this State under this Article.
8    The Illinois Department may require that all dispensers of
9medical services desiring to participate in the medical
10assistance program established under this Article disclose,
11under such terms and conditions as the Illinois Department may
12by rule establish, all inquiries from clients and attorneys
13regarding medical bills paid by the Illinois Department, which
14inquiries could indicate potential existence of claims or liens
15for the Illinois Department.
16    Enrollment of a vendor shall be subject to a provisional
17period and shall be conditional for one year. During the period
18of conditional enrollment, the Department may terminate the
19vendor's eligibility to participate in, or may disenroll the
20vendor from, the medical assistance program without cause.
21Unless otherwise specified, such termination of eligibility or
22disenrollment is not subject to the Department's hearing
23process. However, a disenrolled vendor may reapply without
25    The Department has the discretion to limit the conditional
26enrollment period for vendors based upon category of risk of



HB4013 Engrossed- 20 -LRB099 04328 KTG 24355 b

1the vendor.
2    Prior to enrollment and during the conditional enrollment
3period in the medical assistance program, all vendors shall be
4subject to enhanced oversight, screening, and review based on
5the risk of fraud, waste, and abuse that is posed by the
6category of risk of the vendor. The Illinois Department shall
7establish the procedures for oversight, screening, and review,
8which may include, but need not be limited to: criminal and
9financial background checks; fingerprinting; license,
10certification, and authorization verifications; unscheduled or
11unannounced site visits; database checks; prepayment audit
12reviews; audits; payment caps; payment suspensions; and other
13screening as required by federal or State law.
14    The Department shall define or specify the following: (i)
15by provider notice, the "category of risk of the vendor" for
16each type of vendor, which shall take into account the level of
17screening applicable to a particular category of vendor under
18federal law and regulations; (ii) by rule or provider notice,
19the maximum length of the conditional enrollment period for
20each category of risk of the vendor; and (iii) by rule, the
21hearing rights, if any, afforded to a vendor in each category
22of risk of the vendor that is terminated or disenrolled during
23the conditional enrollment period.
24    To be eligible for payment consideration, a vendor's
25payment claim or bill, either as an initial claim or as a
26resubmitted claim following prior rejection, must be received



HB4013 Engrossed- 21 -LRB099 04328 KTG 24355 b

1by the Illinois Department, or its fiscal intermediary, no
2later than 180 days after the latest date on the claim on which
3medical goods or services were provided, with the following
5        (1) In the case of a provider whose enrollment is in
6    process by the Illinois Department, the 180-day period
7    shall not begin until the date on the written notice from
8    the Illinois Department that the provider enrollment is
9    complete.
10        (2) In the case of errors attributable to the Illinois
11    Department or any of its claims processing intermediaries
12    which result in an inability to receive, process, or
13    adjudicate a claim, the 180-day period shall not begin
14    until the provider has been notified of the error.
15        (3) In the case of a provider for whom the Illinois
16    Department initiates the monthly billing process.
17        (4) In the case of a provider operated by a unit of
18    local government with a population exceeding 3,000,000
19    when local government funds finance federal participation
20    for claims payments.
21    For claims for services rendered during a period for which
22a recipient received retroactive eligibility, claims must be
23filed within 180 days after the Department determines the
24applicant is eligible. For claims for which the Illinois
25Department is not the primary payer, claims must be submitted
26to the Illinois Department within 180 days after the final



HB4013 Engrossed- 22 -LRB099 04328 KTG 24355 b

1adjudication by the primary payer.
2    In the case of long term care facilities, within 5 days of
3receipt by the facility of required prescreening information,
4data for new admissions shall be entered into the Medical
5Electronic Data Interchange (MEDI) or the Recipient
6Eligibility Verification (REV) System or successor system, and
7within 15 days of receipt by the facility of required
8prescreening information, admission documents shall be
9submitted through MEDI or REV or shall be submitted directly to
10the Department of Human Services using required admission
11forms. Effective September 1, 2014, admission documents,
12including all prescreening information, must be submitted
13through MEDI or REV. Confirmation numbers assigned to an
14accepted transaction shall be retained by a facility to verify
15timely submittal. Once an admission transaction has been
16completed, all resubmitted claims following prior rejection
17are subject to receipt no later than 180 days after the
18admission transaction has been completed.
19    Claims that are not submitted and received in compliance
20with the foregoing requirements shall not be eligible for
21payment under the medical assistance program, and the State
22shall have no liability for payment of those claims.
23    To the extent consistent with applicable information and
24privacy, security, and disclosure laws, State and federal
25agencies and departments shall provide the Illinois Department
26access to confidential and other information and data necessary



HB4013 Engrossed- 23 -LRB099 04328 KTG 24355 b

1to perform eligibility and payment verifications and other
2Illinois Department functions. This includes, but is not
3limited to: information pertaining to licensure;
4certification; earnings; immigration status; citizenship; wage
5reporting; unearned and earned income; pension income;
6employment; supplemental security income; social security
7numbers; National Provider Identifier (NPI) numbers; the
8National Practitioner Data Bank (NPDB); program and agency
9exclusions; taxpayer identification numbers; tax delinquency;
10corporate information; and death records.
11    The Illinois Department shall enter into agreements with
12State agencies and departments, and is authorized to enter into
13agreements with federal agencies and departments, under which
14such agencies and departments shall share data necessary for
15medical assistance program integrity functions and oversight.
16The Illinois Department shall develop, in cooperation with
17other State departments and agencies, and in compliance with
18applicable federal laws and regulations, appropriate and
19effective methods to share such data. At a minimum, and to the
20extent necessary to provide data sharing, the Illinois
21Department shall enter into agreements with State agencies and
22departments, and is authorized to enter into agreements with
23federal agencies and departments, including but not limited to:
24the Secretary of State; the Department of Revenue; the
25Department of Public Health; the Department of Human Services;
26and the Department of Financial and Professional Regulation.



HB4013 Engrossed- 24 -LRB099 04328 KTG 24355 b

1    Beginning in fiscal year 2013, the Illinois Department
2shall set forth a request for information to identify the
3benefits of a pre-payment, post-adjudication, and post-edit
4claims system with the goals of streamlining claims processing
5and provider reimbursement, reducing the number of pending or
6rejected claims, and helping to ensure a more transparent
7adjudication process through the utilization of: (i) provider
8data verification and provider screening technology; and (ii)
9clinical code editing; and (iii) pre-pay, pre- or
10post-adjudicated predictive modeling with an integrated case
11management system with link analysis. Such a request for
12information shall not be considered as a request for proposal
13or as an obligation on the part of the Illinois Department to
14take any action or acquire any products or services.
15    The Illinois Department shall establish policies,
16procedures, standards and criteria by rule for the acquisition,
17repair and replacement of orthotic and prosthetic devices and
18durable medical equipment. Such rules shall provide, but not be
19limited to, the following services: (1) immediate repair or
20replacement of such devices by recipients; and (2) rental,
21lease, purchase or lease-purchase of durable medical equipment
22in a cost-effective manner, taking into consideration the
23recipient's medical prognosis, the extent of the recipient's
24needs, and the requirements and costs for maintaining such
25equipment. Subject to prior approval, such rules shall enable a
26recipient to temporarily acquire and use alternative or



HB4013 Engrossed- 25 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 26 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 27 -LRB099 04328 KTG 24355 b

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



HB4013 Engrossed- 28 -LRB099 04328 KTG 24355 b

1this Code, beginning October 1, 2014, the Department shall
2cover kidney transplantation for noncitizens with end-stage
3renal disease who are not eligible for comprehensive medical
4benefits, who meet the residency requirements of Section 5-3 of
5this Code, and who would otherwise meet the financial
6requirements of the appropriate class of eligible persons under
7Section 5-2 of this Code. To qualify for coverage of kidney
8transplantation, such person must be receiving emergency renal
9dialysis services covered by the Department. Providers under
10this Section shall be prior approved and certified by the
11Department to perform kidney transplantation and the services
12under this Section shall be limited to services associated with
13kidney transplantation.
14(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
15eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
169-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
177-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
18eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
19revised 10-2-14.)
20    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
21    Sec. 5-8. Practitioners. In supplying medical assistance,
22the Illinois Department may provide for the legally authorized
23services of (i) persons licensed under the Medical Practice Act
24of 1987, as amended, except as hereafter in this Section
25stated, whether under a general or limited license, (ii)



HB4013 Engrossed- 29 -LRB099 04328 KTG 24355 b

1persons licensed or registered under other laws of this State
2to provide dental, medical, pharmaceutical, optometric,
3podiatric, or nursing services, or other remedial care
4recognized under State law, and (iii) persons licensed under
5other laws of this State as a clinical social worker. The
6Department may not provide for legally authorized services of
7any physician who has been convicted of having performed an
8abortion procedure in a wilful and wanton manner on a woman who
9was not pregnant at the time such abortion procedure was
10performed. The utilization of the services of persons engaged
11in the treatment or care of the sick, which persons are not
12required to be licensed or registered under the laws of this
13State, is not prohibited by this Section.
14(Source: P.A. 95-518, eff. 8-28-07.)
15    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
16    Sec. 5-9. Choice of Medical Dispensers. Applicants and
17recipients shall be entitled to free choice of those qualified
18practitioners, hospitals, nursing homes, and other dispensers
19of medical services meeting the requirements and complying with
20the rules and regulations of the Illinois Department. However,
21the Director of Healthcare and Family Services may, after
22providing reasonable notice and opportunity for hearing, deny,
23suspend or terminate any otherwise qualified person, firm,
24corporation, association, agency, institution, or other legal
25entity, from participation as a vendor of goods or services



HB4013 Engrossed- 30 -LRB099 04328 KTG 24355 b

1under the medical assistance program authorized by this Article
2if the Director finds such vendor of medical services in
3violation of this Act or the policy or rules and regulations
4issued pursuant to this Act. Any physician who has been
5convicted of performing an abortion procedure in a wilful and
6wanton manner upon a woman who was not pregnant at the time
7such abortion procedure was performed shall be automatically
8removed from the list of physicians qualified to participate as
9a vendor of medical services under the medical assistance
10program authorized by this Article.
11(Source: P.A. 95-331, eff. 8-21-07.)
12    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
13    Sec. 6-1. Eligibility requirements. Financial aid in
14meeting basic maintenance requirements shall be given under
15this Article to or in behalf of persons who meet the
16eligibility conditions of Sections 6-1.1 through 6-1.10. In
17addition, each unit of local government subject to this Article
18shall provide persons receiving financial aid in meeting basic
19maintenance requirements with financial aid for either (a)
20necessary treatment, care, and supplies required because of
21illness or disability, or (b) acute medical treatment, care,
22and supplies only. If a local governmental unit elects to
23provide financial aid for acute medical treatment, care, and
24supplies only, the general types of acute medical treatment,
25care, and supplies for which financial aid is provided shall be



HB4013 Engrossed- 31 -LRB099 04328 KTG 24355 b

1specified in the general assistance rules of the local
2governmental unit, which rules shall provide that financial aid
3is provided, at a minimum, for acute medical treatment, care,
4or supplies necessitated by a medical condition for which prior
5approval or authorization of medical treatment, care, or
6supplies is not required by the general assistance rules of the
7Illinois Department. Nothing in this Article shall be construed
8to permit the granting of financial aid where the purpose of
9such aid is to obtain an abortion, induced miscarriage or
10induced premature birth unless, in the opinion of a physician,
11such procedures are necessary for the preservation of the life
12of the woman seeking such treatment, or except an induced
13premature birth intended to produce a live viable child and
14such procedure is necessary for the health of the mother or her
15unborn child.
16(Source: P.A. 92-111, eff. 1-1-02.)
17    Section 15. The Problem Pregnancy Health Services and Care
18Act is amended by changing Section 4-100 as follows:
19    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
20    Sec. 4-100. The Department may make grants to nonprofit
21agencies and organizations which do not use such grants to
22refer or counsel for, or perform, abortions and which
23coordinate and establish linkages among services that will
24further the purposes of this Act and, where appropriate, will



HB4013 Engrossed- 32 -LRB099 04328 KTG 24355 b

1provide, supplement, or improve the quality of such services.
2(Source: P.A. 83-51.)



HB4013 Engrossed- 33 -LRB099 04328 KTG 24355 b

2 Statutes amended in order of appearance
3    5 ILCS 375/6from Ch. 127, par. 526
4    5 ILCS 375/6.1from Ch. 127, par. 526.1
5    305 ILCS 5/5-5from Ch. 23, par. 5-5
6    305 ILCS 5/5-8from Ch. 23, par. 5-8
7    305 ILCS 5/5-9from Ch. 23, par. 5-9
8    305 ILCS 5/6-1from Ch. 23, par. 6-1
9    410 ILCS 230/4-100from Ch. 111 1/2, par. 4604-100