Illinois General Assembly - Full Text of HB5351
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Full Text of HB5351  100th General Assembly




HB5351 EnrolledLRB100 19599 SMS 34870 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.22 as follows:
6    (215 ILCS 5/356z.22)
7    Sec. 356z.22. Coverage for telehealth services.
8    (a) For purposes of this Section:
9    "Distant site" means the location at which the health care
10provider rendering the telehealth service is located.
11    "Interactive telecommunications system" means an audio and
12video system permitting 2-way, live interactive communication
13between the patient and the distant site health care provider.
14    "Telehealth services" means the delivery of covered health
15care services by way of an interactive telecommunications
17    (b) If an individual or group policy of accident or health
18insurance provides coverage for telehealth services, then it
19must comply with the following:
20        (1) An individual or group policy of accident or health
21    insurance providing telehealth services may not:
22            (A) require that in-person contact occur between a
23        health care provider and a patient;



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1            (B) require the health care provider to document a
2        barrier to an in-person consultation for coverage of
3        services to be provided through telehealth;
4            (C) require the use of telehealth when the health
5        care provider has determined that it is not
6        appropriate; or
7            (D) require the use of telehealth when a patient
8        chooses an in-person consultation.
9        (2) Deductibles, copayments, or coinsurance applicable
10    to services provided through telehealth shall not exceed
11    the deductibles, copayments, or coinsurance required by
12    the individual or group policy of accident or health
13    insurance for the same services provided through in-person
14    consultation.
15    (b-5) If an individual or group policy of accident or
16health insurance provides coverage for telehealth services, it
17must provide coverage for licensed dietitian nutritionists and
18certified diabetes educators who counsel senior diabetes
19patients in the senior diabetes patients' homes to remove the
20hurdle of transportation for senior diabetes patients to
21receive treatment.
22    (c) Nothing in this Section shall be deemed as precluding a
23health insurer from providing benefits for other services,
24including, but not limited to, remote monitoring services,
25other monitoring services, or oral communications otherwise
26covered under the policy.



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1(Source: P.A. 98-1091, eff. 1-1-15.)
2    Section 10. The Illinois Public Aid Code is amended by
3changing Section 5-5 as follows:
4    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
5    Sec. 5-5. Medical services. The Illinois Department, by
6rule, shall determine the quantity and quality of and the rate
7of reimbursement for the medical assistance for which payment
8will be authorized, and the medical services to be provided,
9which may include all or part of the following: (1) inpatient
10hospital services; (2) outpatient hospital services; (3) other
11laboratory and X-ray services; (4) skilled nursing home
12services; (5) physicians' services whether furnished in the
13office, the patient's home, a hospital, a skilled nursing home,
14or elsewhere; (6) medical care, or any other type of remedial
15care furnished by licensed practitioners; (7) home health care
16services; (8) private duty nursing service; (9) clinic
17services; (10) dental services, including prevention and
18treatment of periodontal disease and dental caries disease for
19pregnant women, provided by an individual licensed to practice
20dentistry or dental surgery; for purposes of this item (10),
21"dental services" means diagnostic, preventive, or corrective
22procedures provided by or under the supervision of a dentist in
23the practice of his or her profession; (11) physical therapy
24and related services; (12) prescribed drugs, dentures, and



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



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



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1medical assistance program and in any capitated Medicaid
2managed care entity (MCE) serving individuals enrolled in a
3school within the CPS system. Under any contract procured under
4this provision, the vendor or vendors must serve only
5individuals enrolled in a school within the CPS system. Claims
6for services provided by CPS's vendor or vendors to recipients
7of benefits in the medical assistance program under this Code,
8the Children's Health Insurance Program, or the Covering ALL
9KIDS Health Insurance Program shall be submitted to the
10Department or the MCE in which the individual is enrolled for
11payment and shall be reimbursed at the Department's or the
12MCE's established rates or rate methodologies for eyeglasses.
13    On and after July 1, 2012, the Department of Healthcare and
14Family Services may provide the following services to persons
15eligible for assistance under this Article who are
16participating in education, training or employment programs
17operated by the Department of Human Services as successor to
18the Department of Public Aid:
19        (1) dental services provided by or under the
20    supervision of a dentist; and
21        (2) eyeglasses prescribed by a physician skilled in the
22    diseases of the eye, or by an optometrist, whichever the
23    person may select.
24    Notwithstanding any other provision of this Code and
25subject to federal approval, the Department may adopt rules to
26allow a dentist who is volunteering his or her service at no



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1cost to render dental services through an enrolled
2not-for-profit health clinic without the dentist personally
3enrolling as a participating provider in the medical assistance
4program. A not-for-profit health clinic shall include a public
5health clinic or Federally Qualified Health Center or other
6enrolled provider, as determined by the Department, through
7which dental services covered under this Section are performed.
8The Department shall establish a process for payment of claims
9for reimbursement for covered dental services rendered under
10this provision.
11    The Illinois Department, by rule, may distinguish and
12classify the medical services to be provided only in accordance
13with the classes of persons designated in Section 5-2.
14    The Department of Healthcare and Family Services must
15provide coverage and reimbursement for amino acid-based
16elemental formulas, regardless of delivery method, for the
17diagnosis and treatment of (i) eosinophilic disorders and (ii)
18short bowel syndrome when the prescribing physician has issued
19a written order stating that the amino acid-based elemental
20formula is medically necessary.
21    The Illinois Department shall authorize the provision of,
22and shall authorize payment for, screening by low-dose
23mammography for the presence of occult breast cancer for women
2435 years of age or older who are eligible for medical
25assistance under this Article, as follows:
26        (A) A baseline mammogram for women 35 to 39 years of



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



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1tomosynthesis. As used in this Section, the term "breast
2tomosynthesis" means a radiologic procedure that involves the
3acquisition of projection images over the stationary breast to
4produce cross-sectional digital three-dimensional images of
5the breast. If, at any time, the Secretary of the United States
6Department of Health and Human Services, or its successor
7agency, promulgates rules or regulations to be published in the
8Federal Register or publishes a comment in the Federal Register
9or issues an opinion, guidance, or other action that would
10require the State, pursuant to any provision of the Patient
11Protection and Affordable Care Act (Public Law 111-148),
12including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
13successor provision, to defray the cost of any coverage for
14breast tomosynthesis outlined in this paragraph, then the
15requirement that an insurer cover breast tomosynthesis is
16inoperative other than any such coverage authorized under
17Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
18the State shall not assume any obligation for the cost of
19coverage for breast tomosynthesis set forth in this paragraph.
20    On and after January 1, 2016, the Department shall ensure
21that all networks of care for adult clients of the Department
22include access to at least one breast imaging Center of Imaging
23Excellence as certified by the American College of Radiology.
24    On and after January 1, 2012, providers participating in a
25quality improvement program approved by the Department shall be
26reimbursed for screening and diagnostic mammography at the same



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1rate as the Medicare program's rates, including the increased
2reimbursement for digital mammography.
3    The Department shall convene an expert panel including
4representatives of hospitals, free-standing mammography
5facilities, and doctors, including radiologists, to establish
6quality standards for mammography.
7    On and after January 1, 2017, providers participating in a
8breast cancer treatment quality improvement program approved
9by the Department shall be reimbursed for breast cancer
10treatment at a rate that is no lower than 95% of the Medicare
11program's rates for the data elements included in the breast
12cancer treatment quality program.
13    The Department shall convene an expert panel, including
14representatives of hospitals, free standing breast cancer
15treatment centers, breast cancer quality organizations, and
16doctors, including breast surgeons, reconstructive breast
17surgeons, oncologists, and primary care providers to establish
18quality standards for breast cancer treatment.
19    Subject to federal approval, the Department shall
20establish a rate methodology for mammography at federally
21qualified health centers and other encounter-rate clinics.
22These clinics or centers may also collaborate with other
23hospital-based mammography facilities. By January 1, 2016, the
24Department shall report to the General Assembly on the status
25of the provision set forth in this paragraph.
26    The Department shall establish a methodology to remind



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1women who are age-appropriate for screening mammography, but
2who have not received a mammogram within the previous 18
3months, of the importance and benefit of screening mammography.
4The Department shall work with experts in breast cancer
5outreach and patient navigation to optimize these reminders and
6shall establish a methodology for evaluating their
7effectiveness and modifying the methodology based on the
9    The Department shall establish a performance goal for
10primary care providers with respect to their female patients
11over age 40 receiving an annual mammogram. This performance
12goal shall be used to provide additional reimbursement in the
13form of a quality performance bonus to primary care providers
14who meet that goal.
15    The Department shall devise a means of case-managing or
16patient navigation for beneficiaries diagnosed with breast
17cancer. This program shall initially operate as a pilot program
18in areas of the State with the highest incidence of mortality
19related to breast cancer. At least one pilot program site shall
20be in the metropolitan Chicago area and at least one site shall
21be outside the metropolitan Chicago area. On or after July 1,
222016, the pilot program shall be expanded to include one site
23in western Illinois, one site in southern Illinois, one site in
24central Illinois, and 4 sites within metropolitan Chicago. An
25evaluation of the pilot program shall be carried out measuring
26health outcomes and cost of care for those served by the pilot



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1program compared to similarly situated patients who are not
2served by the pilot program.
3    The Department shall require all networks of care to
4develop a means either internally or by contract with experts
5in navigation and community outreach to navigate cancer
6patients to comprehensive care in a timely fashion. The
7Department shall require all networks of care to include access
8for patients diagnosed with cancer to at least one academic
9commission on cancer-accredited cancer program as an
10in-network covered benefit.
11    Any medical or health care provider shall immediately
12recommend, to any pregnant woman who is being provided prenatal
13services and is suspected of drug abuse or is addicted as
14defined in the Alcoholism and Other Drug Abuse and Dependency
15Act, referral to a local substance abuse treatment provider
16licensed by the Department of Human Services or to a licensed
17hospital which provides substance abuse treatment services.
18The Department of Healthcare and Family Services shall assure
19coverage for the cost of treatment of the drug abuse or
20addiction for pregnant recipients in accordance with the
21Illinois Medicaid Program in conjunction with the Department of
22Human Services.
23    All medical providers providing medical assistance to
24pregnant women under this Code shall receive information from
25the Department on the availability of services under the Drug
26Free Families with a Future or any comparable program providing



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



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



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



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1and services provided to recipients of Medical Assistance under
2this Article. Such records must be retained for a period of not
3less than 6 years from the date of service or as provided by
4applicable State law, whichever period is longer, except that
5if an audit is initiated within the required retention period
6then the records must be retained until the audit is completed
7and every exception is resolved. The Illinois Department shall
8require health care providers to make available, when
9authorized by the patient, in writing, the medical records in a
10timely fashion to other health care providers who are treating
11or serving persons eligible for Medical Assistance under this
12Article. All dispensers of medical services shall be required
13to maintain and retain business and professional records
14sufficient to fully and accurately document the nature, scope,
15details and receipt of the health care provided to persons
16eligible for medical assistance under this Code, in accordance
17with regulations promulgated by the Illinois Department. The
18rules and regulations shall require that proof of the receipt
19of prescription drugs, dentures, prosthetic devices and
20eyeglasses by eligible persons under this Section accompany
21each claim for reimbursement submitted by the dispenser of such
22medical services. No such claims for reimbursement shall be
23approved for payment by the Illinois Department without such
24proof of receipt, unless the Illinois Department shall have put
25into effect and shall be operating a system of post-payment
26audit and review which shall, on a sampling basis, be deemed



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1adequate by the Illinois Department to assure that such drugs,
2dentures, prosthetic devices and eyeglasses for which payment
3is being made are actually being received by eligible
4recipients. Within 90 days after September 16, 1984 (the
5effective date of Public Act 83-1439), the Illinois Department
6shall establish a current list of acquisition costs for all
7prosthetic devices and any other items recognized as medical
8equipment and supplies reimbursable under this Article and
9shall update such list on a quarterly basis, except that the
10acquisition costs of all prescription drugs shall be updated no
11less frequently than every 30 days as required by Section
13    Notwithstanding any other law to the contrary, the Illinois
14Department shall, within 365 days after July 22, 2013 (the
15effective date of Public Act 98-104), establish procedures to
16permit skilled care facilities licensed under the Nursing Home
17Care Act to submit monthly billing claims for reimbursement
18purposes. Following development of these procedures, the
19Department shall, by July 1, 2016, test the viability of the
20new system and implement any necessary operational or
21structural changes to its information technology platforms in
22order to allow for the direct acceptance and payment of nursing
23home claims.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, within 365 days after August 15, 2014 (the
26effective date of Public Act 98-963), establish procedures to



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1permit ID/DD facilities licensed under the ID/DD Community Care
2Act and MC/DD facilities licensed under the MC/DD Act to submit
3monthly billing claims for reimbursement purposes. Following
4development of these procedures, the Department shall have an
5additional 365 days to test the viability of the new system and
6to ensure that any necessary operational or structural changes
7to its information technology platforms are implemented.
8    The Illinois Department shall require all dispensers of
9medical services, other than an individual practitioner or
10group of practitioners, desiring to participate in the Medical
11Assistance program established under this Article to disclose
12all financial, beneficial, ownership, equity, surety or other
13interests in any and all firms, corporations, partnerships,
14associations, business enterprises, joint ventures, agencies,
15institutions or other legal entities providing any form of
16health care services in this State under this Article.
17    The Illinois Department may require that all dispensers of
18medical services desiring to participate in the medical
19assistance program established under this Article disclose,
20under such terms and conditions as the Illinois Department may
21by rule establish, all inquiries from clients and attorneys
22regarding medical bills paid by the Illinois Department, which
23inquiries could indicate potential existence of claims or liens
24for the Illinois Department.
25    Enrollment of a vendor shall be subject to a provisional
26period and shall be conditional for one year. During the period



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1of conditional enrollment, the Department may terminate the
2vendor's eligibility to participate in, or may disenroll the
3vendor from, the medical assistance program without cause.
4Unless otherwise specified, such termination of eligibility or
5disenrollment is not subject to the Department's hearing
6process. However, a disenrolled vendor may reapply without
8    The Department has the discretion to limit the conditional
9enrollment period for vendors based upon category of risk of
10the vendor.
11    Prior to enrollment and during the conditional enrollment
12period in the medical assistance program, all vendors shall be
13subject to enhanced oversight, screening, and review based on
14the risk of fraud, waste, and abuse that is posed by the
15category of risk of the vendor. The Illinois Department shall
16establish the procedures for oversight, screening, and review,
17which may include, but need not be limited to: criminal and
18financial background checks; fingerprinting; license,
19certification, and authorization verifications; unscheduled or
20unannounced site visits; database checks; prepayment audit
21reviews; audits; payment caps; payment suspensions; and other
22screening as required by federal or State law.
23    The Department shall define or specify the following: (i)
24by provider notice, the "category of risk of the vendor" for
25each type of vendor, which shall take into account the level of
26screening applicable to a particular category of vendor under



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1federal law and regulations; (ii) by rule or provider notice,
2the maximum length of the conditional enrollment period for
3each category of risk of the vendor; and (iii) by rule, the
4hearing rights, if any, afforded to a vendor in each category
5of risk of the vendor that is terminated or disenrolled during
6the conditional enrollment period.
7    To be eligible for payment consideration, a vendor's
8payment claim or bill, either as an initial claim or as a
9resubmitted claim following prior rejection, must be received
10by the Illinois Department, or its fiscal intermediary, no
11later than 180 days after the latest date on the claim on which
12medical goods or services were provided, with the following
14        (1) In the case of a provider whose enrollment is in
15    process by the Illinois Department, the 180-day period
16    shall not begin until the date on the written notice from
17    the Illinois Department that the provider enrollment is
18    complete.
19        (2) In the case of errors attributable to the Illinois
20    Department or any of its claims processing intermediaries
21    which result in an inability to receive, process, or
22    adjudicate a claim, the 180-day period shall not begin
23    until the provider has been notified of the error.
24        (3) In the case of a provider for whom the Illinois
25    Department initiates the monthly billing process.
26        (4) In the case of a provider operated by a unit of



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1    local government with a population exceeding 3,000,000
2    when local government funds finance federal participation
3    for claims payments.
4    For claims for services rendered during a period for which
5a recipient received retroactive eligibility, claims must be
6filed within 180 days after the Department determines the
7applicant is eligible. For claims for which the Illinois
8Department is not the primary payer, claims must be submitted
9to the Illinois Department within 180 days after the final
10adjudication by the primary payer.
11    In the case of long term care facilities, within 45
12calendar days of receipt by the facility of required
13prescreening information, new admissions with associated
14admission documents shall be submitted through the Medical
15Electronic Data Interchange (MEDI) or the Recipient
16Eligibility Verification (REV) System or shall be submitted
17directly to the Department of Human Services using required
18admission forms. Effective September 1, 2014, admission
19documents, including all prescreening information, must be
20submitted through MEDI or REV. Confirmation numbers assigned to
21an accepted transaction shall be retained by a facility to
22verify timely submittal. Once an admission transaction has been
23completed, all resubmitted claims following prior rejection
24are subject to receipt no later than 180 days after the
25admission transaction has been completed.
26    Claims that are not submitted and received in compliance



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



HB5351 Enrolled- 23 -LRB100 19599 SMS 34870 b

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



HB5351 Enrolled- 24 -LRB100 19599 SMS 34870 b

1replacement of such devices by recipients; and (2) rental,
2lease, purchase or lease-purchase of durable medical equipment
3in a cost-effective manner, taking into consideration the
4recipient's medical prognosis, the extent of the recipient's
5needs, and the requirements and costs for maintaining such
6equipment. Subject to prior approval, such rules shall enable a
7recipient to temporarily acquire and use alternative or
8substitute devices or equipment pending repairs or
9replacements of any device or equipment previously authorized
10for such recipient by the Department. Notwithstanding any
11provision of Section 5-5f to the contrary, the Department may,
12by rule, exempt certain replacement wheelchair parts from prior
13approval and, for wheelchairs, wheelchair parts, wheelchair
14accessories, and related seating and positioning items,
15determine the wholesale price by methods other than actual
16acquisition costs.
17    The Department shall require, by rule, all providers of
18durable medical equipment to be accredited by an accreditation
19organization approved by the federal Centers for Medicare and
20Medicaid Services and recognized by the Department in order to
21bill the Department for providing durable medical equipment to
22recipients. No later than 15 months after the effective date of
23the rule adopted pursuant to this paragraph, all providers must
24meet the accreditation requirement.
25    The Department shall execute, relative to the nursing home
26prescreening project, written inter-agency agreements with the



HB5351 Enrolled- 25 -LRB100 19599 SMS 34870 b

1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the State
6where they are not currently available or are undeveloped; and
7(iii) notwithstanding any other provision of law, subject to
8federal approval, on and after July 1, 2012, an increase in the
9determination of need (DON) scores from 29 to 37 for applicants
10for institutional and home and community-based long term care;
11if and only if federal approval is not granted, the Department
12may, in conjunction with other affected agencies, implement
13utilization controls or changes in benefit packages to
14effectuate a similar savings amount for this population; and
15(iv) no later than July 1, 2013, minimum level of care
16eligibility criteria for institutional and home and
17community-based long term care; and (v) no later than October
181, 2013, establish procedures to permit long term care
19providers access to eligibility scores for individuals with an
20admission date who are seeking or receiving services from the
21long term care provider. In order to select the minimum level
22of care eligibility criteria, the Governor shall establish a
23workgroup that includes affected agency representatives and
24stakeholders representing the institutional and home and
25community-based long term care interests. This Section shall
26not restrict the Department from implementing lower level of



HB5351 Enrolled- 26 -LRB100 19599 SMS 34870 b

1care eligibility criteria for community-based services in
2circumstances where federal approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation and
7programs for monitoring of utilization of health care services
8and facilities, as it affects persons eligible for medical
9assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The filing of one copy of the report with the
25Speaker, one copy with the Minority Leader and one copy with
26the Clerk of the House of Representatives, one copy with the



HB5351 Enrolled- 27 -LRB100 19599 SMS 34870 b

1President, one copy with the Minority Leader and one copy with
2the Secretary of the Senate, one copy with the Legislative
3Research Unit, and such additional copies with the State
4Government Report Distribution Center for the General Assembly
5as is required under paragraph (t) of Section 7 of the State
6Library Act shall be deemed sufficient to comply with this
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14    On and after July 1, 2012, the Department shall reduce any
15rate of reimbursement for services or other payments or alter
16any methodologies authorized by this Code to reduce any rate of
17reimbursement for services or other payments in accordance with
18Section 5-5e.
19    Because kidney transplantation can be an appropriate, cost
20effective alternative to renal dialysis when medically
21necessary and notwithstanding the provisions of Section 1-11 of
22this Code, beginning October 1, 2014, the Department shall
23cover kidney transplantation for noncitizens with end-stage
24renal disease who are not eligible for comprehensive medical
25benefits, who meet the residency requirements of Section 5-3 of
26this Code, and who would otherwise meet the financial



HB5351 Enrolled- 28 -LRB100 19599 SMS 34870 b

1requirements of the appropriate class of eligible persons under
2Section 5-2 of this Code. To qualify for coverage of kidney
3transplantation, such person must be receiving emergency renal
4dialysis services covered by the Department. Providers under
5this Section shall be prior approved and certified by the
6Department to perform kidney transplantation and the services
7under this Section shall be limited to services associated with
8kidney transplantation.
9    Notwithstanding any other provision of this Code to the
10contrary, on or after July 1, 2015, all FDA approved forms of
11medication assisted treatment prescribed for the treatment of
12alcohol dependence or treatment of opioid dependence shall be
13covered under both fee for service and managed care medical
14assistance programs for persons who are otherwise eligible for
15medical assistance under this Article and shall not be subject
16to any (1) utilization control, other than those established
17under the American Society of Addiction Medicine patient
18placement criteria, (2) prior authorization mandate, or (3)
19lifetime restriction limit mandate.
20    On or after July 1, 2015, opioid antagonists prescribed for
21the treatment of an opioid overdose, including the medication
22product, administration devices, and any pharmacy fees related
23to the dispensing and administration of the opioid antagonist,
24shall be covered under the medical assistance program for
25persons who are otherwise eligible for medical assistance under
26this Article. As used in this Section, "opioid antagonist"



HB5351 Enrolled- 29 -LRB100 19599 SMS 34870 b

1means a drug that binds to opioid receptors and blocks or
2inhibits the effect of opioids acting on those receptors,
3including, but not limited to, naloxone hydrochloride or any
4other similarly acting drug approved by the U.S. Food and Drug
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    Notwithstanding any other provision of this Code, the
19Illinois Department shall authorize licensed dietitian
20nutritionists and certified diabetes educators to counsel
21senior diabetes patients in the senior diabetes patients' homes
22to remove the hurdle of transportation for senior diabetes
23patients to receive treatment.
24(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
2599-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
26the effective date of P.A. 99-407); 99-433, eff. 8-21-15;



HB5351 Enrolled- 30 -LRB100 19599 SMS 34870 b

199-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
27-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
3eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
4100-538, eff. 1-1-18; revised 10-26-17.)