Full Text of SB0420 99th General Assembly
SB0420ham001 99TH GENERAL ASSEMBLY | Rep. Barbara Flynn Currie Filed: 5/18/2016
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| 1 | | AMENDMENT TO SENATE BILL 420
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 420 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 5-5 as follows:
| 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | (Text of Section before amendment by P.A. 99-407 ) | 8 | | Sec. 5-5. Medical services. The Illinois Department, by | 9 | | rule, shall
determine the quantity and quality of and the rate | 10 | | of reimbursement for the
medical assistance for which
payment | 11 | | will be authorized, and the medical services to be provided,
| 12 | | which may include all or part of the following: (1) inpatient | 13 | | hospital
services; (2) outpatient hospital services; (3) other | 14 | | laboratory and
X-ray services; (4) skilled nursing home | 15 | | services; (5) physicians'
services whether furnished in the | 16 | | office, the patient's home, a
hospital, a skilled nursing home, |
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| 1 | | or elsewhere; (6) medical care, or any
other type of remedial | 2 | | care furnished by licensed practitioners; (7)
home health care | 3 | | services; (8) private duty nursing service; (9) clinic
| 4 | | services; (10) dental services, including prevention and | 5 | | treatment of periodontal disease and dental caries disease for | 6 | | pregnant women, provided by an individual licensed to practice | 7 | | dentistry or dental surgery; for purposes of this item (10), | 8 | | "dental services" means diagnostic, preventive, or corrective | 9 | | procedures provided by or under the supervision of a dentist in | 10 | | the practice of his or her profession; (11) physical therapy | 11 | | and related
services; (12) prescribed drugs, dentures, and | 12 | | prosthetic devices; and
eyeglasses prescribed by a physician | 13 | | skilled in the diseases of the eye,
or by an optometrist, | 14 | | whichever the person may select; (13) other
diagnostic, | 15 | | screening, preventive, and rehabilitative services, including | 16 | | to ensure that the individual's need for intervention or | 17 | | treatment of mental disorders or substance use disorders or | 18 | | co-occurring mental health and substance use disorders is | 19 | | determined using a uniform screening, assessment, and | 20 | | evaluation process inclusive of criteria, for children and | 21 | | adults; for purposes of this item (13), a uniform screening, | 22 | | assessment, and evaluation process refers to a process that | 23 | | includes an appropriate evaluation and, as warranted, a | 24 | | referral; "uniform" does not mean the use of a singular | 25 | | instrument, tool, or process that all must utilize; (14)
| 26 | | transportation and such other expenses as may be necessary; |
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| 1 | | (15) medical
treatment of sexual assault survivors, as defined | 2 | | in
Section 1a of the Sexual Assault Survivors Emergency | 3 | | Treatment Act, for
injuries sustained as a result of the sexual | 4 | | assault, including
examinations and laboratory tests to | 5 | | discover evidence which may be used in
criminal proceedings | 6 | | arising from the sexual assault; (16) the
diagnosis and | 7 | | treatment of sickle cell anemia; and (17)
any other medical | 8 | | care, and any other type of remedial care recognized
under the | 9 | | laws of this State, but not including abortions, or induced
| 10 | | miscarriages or premature births, unless, in the opinion of a | 11 | | physician,
such procedures are necessary for the preservation | 12 | | of the life of the
woman seeking such treatment, or except an | 13 | | induced premature birth
intended to produce a live viable child | 14 | | and such procedure is necessary
for the health of the mother or | 15 | | her unborn child. The Illinois Department,
by rule, shall | 16 | | prohibit any physician from providing medical assistance
to | 17 | | anyone eligible therefor under this Code where such physician | 18 | | has been
found guilty of performing an abortion procedure in a | 19 | | wilful and wanton
manner upon a woman who was not pregnant at | 20 | | the time such abortion
procedure was performed. The term "any | 21 | | other type of remedial care" shall
include nursing care and | 22 | | nursing home service for persons who rely on
treatment by | 23 | | spiritual means alone through prayer for healing.
| 24 | | Notwithstanding any other provision of this Section, a | 25 | | comprehensive
tobacco use cessation program that includes | 26 | | purchasing prescription drugs or
prescription medical devices |
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| 1 | | approved by the Food and Drug Administration shall
be covered | 2 | | under the medical assistance
program under this Article for | 3 | | persons who are otherwise eligible for
assistance under this | 4 | | Article.
| 5 | | Notwithstanding any other provision of this Code, the | 6 | | Illinois
Department may not require, as a condition of payment | 7 | | for any laboratory
test authorized under this Article, that a | 8 | | physician's handwritten signature
appear on the laboratory | 9 | | test order form. The Illinois Department may,
however, impose | 10 | | other appropriate requirements regarding laboratory test
order | 11 | | documentation.
| 12 | | Upon receipt of federal approval of an amendment to the | 13 | | Illinois Title XIX State Plan for this purpose, the Department | 14 | | shall authorize the Chicago Public Schools (CPS) to procure a | 15 | | vendor or vendors to manufacture eyeglasses for individuals | 16 | | enrolled in a school within the CPS system. CPS shall ensure | 17 | | that its vendor or vendors are enrolled as providers in the | 18 | | medical assistance program and in any capitated Medicaid | 19 | | managed care entity (MCE) serving individuals enrolled in a | 20 | | school within the CPS system. Under any contract procured under | 21 | | this provision, the vendor or vendors must serve only | 22 | | individuals enrolled in a school within the CPS system. Claims | 23 | | for services provided by CPS's vendor or vendors to recipients | 24 | | of benefits in the medical assistance program under this Code, | 25 | | the Children's Health Insurance Program, or the Covering ALL | 26 | | KIDS Health Insurance Program shall be submitted to the |
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| 1 | | Department or the MCE in which the individual is enrolled for | 2 | | payment and shall be reimbursed at the Department's or the | 3 | | MCE's established rates or rate methodologies for eyeglasses. | 4 | | On and after July 1, 2012, the Department of Healthcare and | 5 | | Family Services may provide the following services to
persons
| 6 | | eligible for assistance under this Article who are | 7 | | participating in
education, training or employment programs | 8 | | operated by the Department of Human
Services as successor to | 9 | | the Department of Public Aid:
| 10 | | (1) dental services provided by or under the | 11 | | supervision of a dentist; and
| 12 | | (2) eyeglasses prescribed by a physician skilled in the | 13 | | diseases of the
eye, or by an optometrist, whichever the | 14 | | person may select.
| 15 | | Notwithstanding any other provision of this Code and | 16 | | subject to federal approval, the Department may adopt rules to | 17 | | allow a dentist who is volunteering his or her service at no | 18 | | cost to render dental services through an enrolled | 19 | | not-for-profit health clinic without the dentist personally | 20 | | enrolling as a participating provider in the medical assistance | 21 | | program. A not-for-profit health clinic shall include a public | 22 | | health clinic or Federally Qualified Health Center or other | 23 | | enrolled provider, as determined by the Department, through | 24 | | which dental services covered under this Section are performed. | 25 | | The Department shall establish a process for payment of claims | 26 | | for reimbursement for covered dental services rendered under |
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| 1 | | this provision. | 2 | | The Illinois Department, by rule, may distinguish and | 3 | | classify the
medical services to be provided only in accordance | 4 | | with the classes of
persons designated in Section 5-2.
| 5 | | The Department of Healthcare and Family Services must | 6 | | provide coverage and reimbursement for amino acid-based | 7 | | elemental formulas, regardless of delivery method, for the | 8 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 9 | | short bowel syndrome when the prescribing physician has issued | 10 | | a written order stating that the amino acid-based elemental | 11 | | formula is medically necessary.
| 12 | | The Illinois Department shall authorize the provision of, | 13 | | and shall
authorize payment for, screening by low-dose | 14 | | mammography for the presence of
occult breast cancer for women | 15 | | 35 years of age or older who are eligible
for medical | 16 | | assistance under this Article, as follows: | 17 | | (A) A baseline
mammogram for women 35 to 39 years of | 18 | | age.
| 19 | | (B) An annual mammogram for women 40 years of age or | 20 | | older. | 21 | | (C) A mammogram at the age and intervals considered | 22 | | medically necessary by the woman's health care provider for | 23 | | women under 40 years of age and having a family history of | 24 | | breast cancer, prior personal history of breast cancer, | 25 | | positive genetic testing, or other risk factors. | 26 | | (D) A comprehensive ultrasound screening of an entire |
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| 1 | | breast or breasts if a mammogram demonstrates | 2 | | heterogeneous or dense breast tissue, when medically | 3 | | necessary as determined by a physician licensed to practice | 4 | | medicine in all of its branches. | 5 | | (E) A screening MRI when medically necessary, as | 6 | | determined by a physician licensed to practice medicine in | 7 | | all of its branches. | 8 | | All screenings
shall
include a physical breast exam, | 9 | | instruction on self-examination and
information regarding the | 10 | | frequency of self-examination and its value as a
preventative | 11 | | tool. For purposes of this Section, "low-dose mammography" | 12 | | means
the x-ray examination of the breast using equipment | 13 | | dedicated specifically
for mammography, including the x-ray | 14 | | tube, filter, compression device,
and image receptor, with an | 15 | | average radiation exposure delivery
of less than one rad per | 16 | | breast for 2 views of an average size breast.
The term also | 17 | | includes digital mammography.
| 18 | | On and after January 1, 2016, the Department shall ensure | 19 | | that all networks of care for adult clients of the Department | 20 | | include access to at least one breast imaging Center of Imaging | 21 | | Excellence as certified by the American College of Radiology. | 22 | | On and after January 1, 2012, providers participating in a | 23 | | quality improvement program approved by the Department shall be | 24 | | reimbursed for screening and diagnostic mammography at the same | 25 | | rate as the Medicare program's rates, including the increased | 26 | | reimbursement for digital mammography. |
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| 1 | | The Department shall convene an expert panel including | 2 | | representatives of hospitals, free-standing mammography | 3 | | facilities, and doctors, including radiologists, to establish | 4 | | quality standards for mammography. | 5 | | On and after January 1, 2017, providers participating in a | 6 | | breast cancer treatment quality improvement program approved | 7 | | by the Department shall be reimbursed for breast cancer | 8 | | treatment at a rate that is no lower than 95% of the Medicare | 9 | | program's rates for the data elements included in the breast | 10 | | cancer treatment quality program. | 11 | | The Department shall convene an expert panel, including | 12 | | representatives of hospitals, free standing breast cancer | 13 | | treatment centers, breast cancer quality organizations, and | 14 | | doctors, including breast surgeons, reconstructive breast | 15 | | surgeons, oncologists, and primary care providers to establish | 16 | | quality standards for breast cancer treatment. | 17 | | Subject to federal approval, the Department shall | 18 | | establish a rate methodology for mammography at federally | 19 | | qualified health centers and other encounter-rate clinics. | 20 | | These clinics or centers may also collaborate with other | 21 | | hospital-based mammography facilities. By January 1, 2016, the | 22 | | Department shall report to the General Assembly on the status | 23 | | of the provision set forth in this paragraph. | 24 | | The Department shall establish a methodology to remind | 25 | | women who are age-appropriate for screening mammography, but | 26 | | who have not received a mammogram within the previous 18 |
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| 1 | | months, of the importance and benefit of screening mammography. | 2 | | The Department shall work with experts in breast cancer | 3 | | outreach and patient navigation to optimize these reminders and | 4 | | shall establish a methodology for evaluating their | 5 | | effectiveness and modifying the methodology based on the | 6 | | evaluation. | 7 | | The Department shall establish a performance goal for | 8 | | primary care providers with respect to their female patients | 9 | | over age 40 receiving an annual mammogram. This performance | 10 | | goal shall be used to provide additional reimbursement in the | 11 | | form of a quality performance bonus to primary care providers | 12 | | who meet that goal. | 13 | | The Department shall devise a means of case-managing or | 14 | | patient navigation for beneficiaries diagnosed with breast | 15 | | cancer. This program shall initially operate as a pilot program | 16 | | in areas of the State with the highest incidence of mortality | 17 | | related to breast cancer. At least one pilot program site shall | 18 | | be in the metropolitan Chicago area and at least one site shall | 19 | | be outside the metropolitan Chicago area. On or after July 1, | 20 | | 2016, the pilot program shall be expanded to include one site | 21 | | in western Illinois, one site in southern Illinois, one site in | 22 | | central Illinois, and 4 sites within metropolitan Chicago. An | 23 | | evaluation of the pilot program shall be carried out measuring | 24 | | health outcomes and cost of care for those served by the pilot | 25 | | program compared to similarly situated patients who are not | 26 | | served by the pilot program. |
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| 1 | | The Department shall require all networks of care to | 2 | | develop a means either internally or by contract with experts | 3 | | in navigation and community outreach to navigate cancer | 4 | | patients to comprehensive care in a timely fashion. The | 5 | | Department shall require all networks of care to include access | 6 | | for patients diagnosed with cancer to at least one academic | 7 | | commission on cancer-accredited cancer program as an | 8 | | in-network covered benefit. | 9 | | Any medical or health care provider shall immediately | 10 | | recommend, to
any pregnant woman who is being provided prenatal | 11 | | services and is suspected
of drug abuse or is addicted as | 12 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 13 | | Act, referral to a local substance abuse treatment provider
| 14 | | licensed by the Department of Human Services or to a licensed
| 15 | | hospital which provides substance abuse treatment services. | 16 | | The Department of Healthcare and Family Services
shall assure | 17 | | coverage for the cost of treatment of the drug abuse or
| 18 | | addiction for pregnant recipients in accordance with the | 19 | | Illinois Medicaid
Program in conjunction with the Department of | 20 | | Human Services.
| 21 | | All medical providers providing medical assistance to | 22 | | pregnant women
under this Code shall receive information from | 23 | | the Department on the
availability of services under the Drug | 24 | | Free Families with a Future or any
comparable program providing | 25 | | case management services for addicted women,
including | 26 | | information on appropriate referrals for other social services
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| 1 | | that may be needed by addicted women in addition to treatment | 2 | | for addiction.
| 3 | | The Illinois Department, in cooperation with the | 4 | | Departments of Human
Services (as successor to the Department | 5 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 6 | | public awareness campaign, may
provide information concerning | 7 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 8 | | health care, and other pertinent programs directed at
reducing | 9 | | the number of drug-affected infants born to recipients of | 10 | | medical
assistance.
| 11 | | Neither the Department of Healthcare and Family Services | 12 | | nor the Department of Human
Services shall sanction the | 13 | | recipient solely on the basis of
her substance abuse.
| 14 | | The Illinois Department shall establish such regulations | 15 | | governing
the dispensing of health services under this Article | 16 | | as it shall deem
appropriate. The Department
should
seek the | 17 | | advice of formal professional advisory committees appointed by
| 18 | | the Director of the Illinois Department for the purpose of | 19 | | providing regular
advice on policy and administrative matters, | 20 | | information dissemination and
educational activities for | 21 | | medical and health care providers, and
consistency in | 22 | | procedures to the Illinois Department.
| 23 | | The Illinois Department may develop and contract with | 24 | | Partnerships of
medical providers to arrange medical services | 25 | | for persons eligible under
Section 5-2 of this Code. | 26 | | Implementation of this Section may be by
demonstration projects |
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| 1 | | in certain geographic areas. The Partnership shall
be | 2 | | represented by a sponsor organization. The Department, by rule, | 3 | | shall
develop qualifications for sponsors of Partnerships. | 4 | | Nothing in this
Section shall be construed to require that the | 5 | | sponsor organization be a
medical organization.
| 6 | | The sponsor must negotiate formal written contracts with | 7 | | medical
providers for physician services, inpatient and | 8 | | outpatient hospital care,
home health services, treatment for | 9 | | alcoholism and substance abuse, and
other services determined | 10 | | necessary by the Illinois Department by rule for
delivery by | 11 | | Partnerships. Physician services must include prenatal and
| 12 | | obstetrical care. The Illinois Department shall reimburse | 13 | | medical services
delivered by Partnership providers to clients | 14 | | in target areas according to
provisions of this Article and the | 15 | | Illinois Health Finance Reform Act,
except that:
| 16 | | (1) Physicians participating in a Partnership and | 17 | | providing certain
services, which shall be determined by | 18 | | the Illinois Department, to persons
in areas covered by the | 19 | | Partnership may receive an additional surcharge
for such | 20 | | services.
| 21 | | (2) The Department may elect to consider and negotiate | 22 | | financial
incentives to encourage the development of | 23 | | Partnerships and the efficient
delivery of medical care.
| 24 | | (3) Persons receiving medical services through | 25 | | Partnerships may receive
medical and case management | 26 | | services above the level usually offered
through the |
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| 1 | | medical assistance program.
| 2 | | Medical providers shall be required to meet certain | 3 | | qualifications to
participate in Partnerships to ensure the | 4 | | delivery of high quality medical
services. These | 5 | | qualifications shall be determined by rule of the Illinois
| 6 | | Department and may be higher than qualifications for | 7 | | participation in the
medical assistance program. Partnership | 8 | | sponsors may prescribe reasonable
additional qualifications | 9 | | for participation by medical providers, only with
the prior | 10 | | written approval of the Illinois Department.
| 11 | | Nothing in this Section shall limit the free choice of | 12 | | practitioners,
hospitals, and other providers of medical | 13 | | services by clients.
In order to ensure patient freedom of | 14 | | choice, the Illinois Department shall
immediately promulgate | 15 | | all rules and take all other necessary actions so that
provided | 16 | | services may be accessed from therapeutically certified | 17 | | optometrists
to the full extent of the Illinois Optometric | 18 | | Practice Act of 1987 without
discriminating between service | 19 | | providers.
| 20 | | The Department shall apply for a waiver from the United | 21 | | States Health
Care Financing Administration to allow for the | 22 | | implementation of
Partnerships under this Section.
| 23 | | The Illinois Department shall require health care | 24 | | providers to maintain
records that document the medical care | 25 | | and services provided to recipients
of Medical Assistance under | 26 | | this Article. Such records must be retained for a period of not |
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| 1 | | less than 6 years from the date of service or as provided by | 2 | | applicable State law, whichever period is longer, except that | 3 | | if an audit is initiated within the required retention period | 4 | | then the records must be retained until the audit is completed | 5 | | and every exception is resolved. The Illinois Department shall
| 6 | | require health care providers to make available, when | 7 | | authorized by the
patient, in writing, the medical records in a | 8 | | timely fashion to other
health care providers who are treating | 9 | | or serving persons eligible for
Medical Assistance under this | 10 | | Article. All dispensers of medical services
shall be required | 11 | | to maintain and retain business and professional records
| 12 | | sufficient to fully and accurately document the nature, scope, | 13 | | details and
receipt of the health care provided to persons | 14 | | eligible for medical
assistance under this Code, in accordance | 15 | | with regulations promulgated by
the Illinois Department. The | 16 | | rules and regulations shall require that proof
of the receipt | 17 | | of prescription drugs, dentures, prosthetic devices and
| 18 | | eyeglasses by eligible persons under this Section accompany | 19 | | each claim
for reimbursement submitted by the dispenser of such | 20 | | medical services.
No such claims for reimbursement shall be | 21 | | approved for payment by the Illinois
Department without such | 22 | | proof of receipt, unless the Illinois Department
shall have put | 23 | | into effect and shall be operating a system of post-payment
| 24 | | audit and review which shall, on a sampling basis, be deemed | 25 | | adequate by
the Illinois Department to assure that such drugs, | 26 | | dentures, prosthetic
devices and eyeglasses for which payment |
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| 1 | | is being made are actually being
received by eligible | 2 | | recipients. Within 90 days after September 16, 1984 ( the | 3 | | effective date of Public Act 83-1439)
this amendatory Act of | 4 | | 1984 , the Illinois Department shall establish a
current list of | 5 | | acquisition costs for all prosthetic devices and any
other | 6 | | items recognized as medical equipment and supplies | 7 | | reimbursable under
this Article and shall update such list on a | 8 | | quarterly basis, except that
the acquisition costs of all | 9 | | prescription drugs shall be updated no
less frequently than | 10 | | every 30 days as required by Section 5-5.12.
| 11 | | The rules and regulations of the Illinois Department shall | 12 | | require
that a written statement including the required opinion | 13 | | of a physician
shall accompany any claim for reimbursement for | 14 | | abortions, or induced
miscarriages or premature births. This | 15 | | statement shall indicate what
procedures were used in providing | 16 | | such medical services.
| 17 | | Notwithstanding any other law to the contrary, the Illinois | 18 | | Department shall, within 365 days after July 22, 2013 (the | 19 | | effective date of Public Act 98-104), establish procedures to | 20 | | permit skilled care facilities licensed under the Nursing Home | 21 | | Care Act to submit monthly billing claims for reimbursement | 22 | | purposes. Following development of these procedures, the | 23 | | Department shall, by July 1, 2016, test the viability of the | 24 | | new system and implement any necessary operational or | 25 | | structural changes to its information technology platforms in | 26 | | order to allow for the direct acceptance and payment of nursing |
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| 1 | | home claims. | 2 | | Notwithstanding any other law to the contrary, the Illinois | 3 | | Department shall, within 365 days after August 15, 2014 (the | 4 | | effective date of Public Act 98-963), establish procedures to | 5 | | permit ID/DD facilities licensed under the ID/DD Community Care | 6 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 7 | | monthly billing claims for reimbursement purposes. Following | 8 | | development of these procedures, the Department shall have an | 9 | | additional 365 days to test the viability of the new system and | 10 | | to ensure that any necessary operational or structural changes | 11 | | to its information technology platforms are implemented. | 12 | | The Illinois Department shall require all dispensers of | 13 | | medical
services, other than an individual practitioner or | 14 | | group of practitioners,
desiring to participate in the Medical | 15 | | Assistance program
established under this Article to disclose | 16 | | all financial, beneficial,
ownership, equity, surety or other | 17 | | interests in any and all firms,
corporations, partnerships, | 18 | | associations, business enterprises, joint
ventures, agencies, | 19 | | institutions or other legal entities providing any
form of | 20 | | health care services in this State under this Article.
| 21 | | The Illinois Department may require that all dispensers of | 22 | | medical
services desiring to participate in the medical | 23 | | assistance program
established under this Article disclose, | 24 | | under such terms and conditions as
the Illinois Department may | 25 | | by rule establish, all inquiries from clients
and attorneys | 26 | | regarding medical bills paid by the Illinois Department, which
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| 1 | | inquiries could indicate potential existence of claims or liens | 2 | | for the
Illinois Department.
| 3 | | Enrollment of a vendor
shall be
subject to a provisional | 4 | | period and shall be conditional for one year. During the period | 5 | | of conditional enrollment, the Department may
terminate the | 6 | | vendor's eligibility to participate in, or may disenroll the | 7 | | vendor from, the medical assistance
program without cause. | 8 | | Unless otherwise specified, such termination of eligibility or | 9 | | disenrollment is not subject to the
Department's hearing | 10 | | process.
However, a disenrolled vendor may reapply without | 11 | | penalty.
| 12 | | The Department has the discretion to limit the conditional | 13 | | enrollment period for vendors based upon category of risk of | 14 | | the vendor. | 15 | | Prior to enrollment and during the conditional enrollment | 16 | | period in the medical assistance program, all vendors shall be | 17 | | subject to enhanced oversight, screening, and review based on | 18 | | the risk of fraud, waste, and abuse that is posed by the | 19 | | category of risk of the vendor. The Illinois Department shall | 20 | | establish the procedures for oversight, screening, and review, | 21 | | which may include, but need not be limited to: criminal and | 22 | | financial background checks; fingerprinting; license, | 23 | | certification, and authorization verifications; unscheduled or | 24 | | unannounced site visits; database checks; prepayment audit | 25 | | reviews; audits; payment caps; payment suspensions; and other | 26 | | screening as required by federal or State law. |
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| 1 | | The Department shall define or specify the following: (i) | 2 | | by provider notice, the "category of risk of the vendor" for | 3 | | each type of vendor, which shall take into account the level of | 4 | | screening applicable to a particular category of vendor under | 5 | | federal law and regulations; (ii) by rule or provider notice, | 6 | | the maximum length of the conditional enrollment period for | 7 | | each category of risk of the vendor; and (iii) by rule, the | 8 | | hearing rights, if any, afforded to a vendor in each category | 9 | | of risk of the vendor that is terminated or disenrolled during | 10 | | the conditional enrollment period. | 11 | | To be eligible for payment consideration, a vendor's | 12 | | payment claim or bill, either as an initial claim or as a | 13 | | resubmitted claim following prior rejection, must be received | 14 | | by the Illinois Department, or its fiscal intermediary, no | 15 | | later than 180 days after the latest date on the claim on which | 16 | | medical goods or services were provided, with the following | 17 | | exceptions: | 18 | | (1) In the case of a provider whose enrollment is in | 19 | | process by the Illinois Department, the 180-day period | 20 | | shall not begin until the date on the written notice from | 21 | | the Illinois Department that the provider enrollment is | 22 | | complete. | 23 | | (2) In the case of errors attributable to the Illinois | 24 | | Department or any of its claims processing intermediaries | 25 | | which result in an inability to receive, process, or | 26 | | adjudicate a claim, the 180-day period shall not begin |
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| 1 | | until the provider has been notified of the error. | 2 | | (3) In the case of a provider for whom the Illinois | 3 | | Department initiates the monthly billing process. | 4 | | (4) In the case of a provider operated by a unit of | 5 | | local government with a population exceeding 3,000,000 | 6 | | when local government funds finance federal participation | 7 | | for claims payments. | 8 | | For claims for services rendered during a period for which | 9 | | a recipient received retroactive eligibility, claims must be | 10 | | filed within 180 days after the Department determines the | 11 | | applicant is eligible. For claims for which the Illinois | 12 | | Department is not the primary payer, claims must be submitted | 13 | | to the Illinois Department within 180 days after the final | 14 | | adjudication by the primary payer. | 15 | | In the case of long term care facilities, within 5 days of | 16 | | receipt by the facility of required prescreening information, | 17 | | data for new admissions shall be entered into the Medical | 18 | | Electronic Data Interchange (MEDI) or the Recipient | 19 | | Eligibility Verification (REV) System or successor system, and | 20 | | within 15 days of receipt by the facility of required | 21 | | prescreening information, admission documents shall be | 22 | | submitted through MEDI or REV or shall be submitted directly to | 23 | | the Department of Human Services using required admission | 24 | | forms. Effective September
1, 2014, admission documents, | 25 | | including all prescreening
information, must be submitted | 26 | | through MEDI or REV. Confirmation numbers assigned to an |
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| 1 | | accepted transaction shall be retained by a facility to verify | 2 | | timely submittal. Once an admission transaction has been | 3 | | completed, all resubmitted claims following prior rejection | 4 | | are subject to receipt no later than 180 days after the | 5 | | admission transaction has been completed. | 6 | | Claims that are not submitted and received in compliance | 7 | | with the foregoing requirements shall not be eligible for | 8 | | payment under the medical assistance program, and the State | 9 | | shall have no liability for payment of those claims. | 10 | | To the extent consistent with applicable information and | 11 | | privacy, security, and disclosure laws, State and federal | 12 | | agencies and departments shall provide the Illinois Department | 13 | | access to confidential and other information and data necessary | 14 | | to perform eligibility and payment verifications and other | 15 | | Illinois Department functions. This includes, but is not | 16 | | limited to: information pertaining to licensure; | 17 | | certification; earnings; immigration status; citizenship; wage | 18 | | reporting; unearned and earned income; pension income; | 19 | | employment; supplemental security income; social security | 20 | | numbers; National Provider Identifier (NPI) numbers; the | 21 | | National Practitioner Data Bank (NPDB); program and agency | 22 | | exclusions; taxpayer identification numbers; tax delinquency; | 23 | | corporate information; and death records. | 24 | | The Illinois Department shall enter into agreements with | 25 | | State agencies and departments, and is authorized to enter into | 26 | | agreements with federal agencies and departments, under which |
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| 1 | | such agencies and departments shall share data necessary for | 2 | | medical assistance program integrity functions and oversight. | 3 | | The Illinois Department shall develop, in cooperation with | 4 | | other State departments and agencies, and in compliance with | 5 | | applicable federal laws and regulations, appropriate and | 6 | | effective methods to share such data. At a minimum, and to the | 7 | | extent necessary to provide data sharing, the Illinois | 8 | | Department shall enter into agreements with State agencies and | 9 | | departments, and is authorized to enter into agreements with | 10 | | federal agencies and departments, including but not limited to: | 11 | | the Secretary of State; the Department of Revenue; the | 12 | | Department of Public Health; the Department of Human Services; | 13 | | and the Department of Financial and Professional Regulation. | 14 | | Beginning in fiscal year 2013, the Illinois Department | 15 | | shall set forth a request for information to identify the | 16 | | benefits of a pre-payment, post-adjudication, and post-edit | 17 | | claims system with the goals of streamlining claims processing | 18 | | and provider reimbursement, reducing the number of pending or | 19 | | rejected claims, and helping to ensure a more transparent | 20 | | adjudication process through the utilization of: (i) provider | 21 | | data verification and provider screening technology; and (ii) | 22 | | clinical code editing; and (iii) pre-pay, pre- or | 23 | | post-adjudicated predictive modeling with an integrated case | 24 | | management system with link analysis. Such a request for | 25 | | information shall not be considered as a request for proposal | 26 | | or as an obligation on the part of the Illinois Department to |
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| 1 | | take any action or acquire any products or services. | 2 | | The Illinois Department shall establish policies, | 3 | | procedures,
standards and criteria by rule for the acquisition, | 4 | | repair and replacement
of orthotic and prosthetic devices and | 5 | | durable medical equipment. Such
rules shall provide, but not be | 6 | | limited to, the following services: (1)
immediate repair or | 7 | | replacement of such devices by recipients; and (2) rental, | 8 | | lease, purchase or lease-purchase of
durable medical equipment | 9 | | in a cost-effective manner, taking into
consideration the | 10 | | recipient's medical prognosis, the extent of the
recipient's | 11 | | needs, and the requirements and costs for maintaining such
| 12 | | equipment. Subject to prior approval, such rules shall enable a | 13 | | recipient to temporarily acquire and
use alternative or | 14 | | substitute devices or equipment pending repairs or
| 15 | | replacements of any device or equipment previously authorized | 16 | | for such
recipient by the Department. Notwithstanding any | 17 | | provision of Section 5-5f to the contrary, the Department may, | 18 | | by rule, exempt certain replacement wheelchair parts from prior | 19 | | approval and determine the wholesale price by methods other | 20 | | than actual acquisition costs.
| 21 | | The Department shall require, by rule, all providers of | 22 | | durable medical equipment to be accredited by an accreditation | 23 | | organization approved by the federal Centers for Medicare and | 24 | | Medicaid Services and recognized by the Department in order to | 25 | | bill the Department for providing durable medical equipment to | 26 | | recipients. No later than 15 months after the effective date of |
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| 1 | | the rule adopted pursuant to this paragraph, all providers must | 2 | | meet the accreditation requirement. | 3 | | The Department shall execute, relative to the nursing home | 4 | | prescreening
project, written inter-agency agreements with the | 5 | | Department of Human
Services and the Department on Aging, to | 6 | | effect the following: (i) intake
procedures and common | 7 | | eligibility criteria for those persons who are receiving
| 8 | | non-institutional services; and (ii) the establishment and | 9 | | development of
non-institutional services in areas of the State | 10 | | where they are not currently
available or are undeveloped; and | 11 | | (iii) notwithstanding any other provision of law, subject to | 12 | | federal approval, on and after July 1, 2012, an increase in the | 13 | | determination of need (DON) scores from 29 to 37 for applicants | 14 | | for institutional and home and community-based long term care; | 15 | | if and only if federal approval is not granted, the Department | 16 | | may, in conjunction with other affected agencies, implement | 17 | | utilization controls or changes in benefit packages to | 18 | | effectuate a similar savings amount for this population; and | 19 | | (iv) no later than July 1, 2013, minimum level of care | 20 | | eligibility criteria for institutional and home and | 21 | | community-based long term care; and (v) no later than October | 22 | | 1, 2013, establish procedures to permit long term care | 23 | | providers access to eligibility scores for individuals with an | 24 | | admission date who are seeking or receiving services from the | 25 | | long term care provider. In order to select the minimum level | 26 | | of care eligibility criteria, the Governor shall establish a |
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| 1 | | workgroup that includes affected agency representatives and | 2 | | stakeholders representing the institutional and home and | 3 | | community-based long term care interests. This Section shall | 4 | | not restrict the Department from implementing lower level of | 5 | | care eligibility criteria for community-based services in | 6 | | circumstances where federal approval has been granted.
| 7 | | The Illinois Department shall develop and operate, in | 8 | | cooperation
with other State Departments and agencies and in | 9 | | compliance with
applicable federal laws and regulations, | 10 | | appropriate and effective
systems of health care evaluation and | 11 | | programs for monitoring of
utilization of health care services | 12 | | and facilities, as it affects
persons eligible for medical | 13 | | assistance under this Code.
| 14 | | The Illinois Department shall report annually to the | 15 | | General Assembly,
no later than the second Friday in April of | 16 | | 1979 and each year
thereafter, in regard to:
| 17 | | (a) actual statistics and trends in utilization of | 18 | | medical services by
public aid recipients;
| 19 | | (b) actual statistics and trends in the provision of | 20 | | the various medical
services by medical vendors;
| 21 | | (c) current rate structures and proposed changes in | 22 | | those rate structures
for the various medical vendors; and
| 23 | | (d) efforts at utilization review and control by the | 24 | | Illinois Department.
| 25 | | The period covered by each report shall be the 3 years | 26 | | ending on the June
30 prior to the report. The report shall |
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| 1 | | include suggested legislation
for consideration by the General | 2 | | Assembly. The filing of one copy of the
report with the | 3 | | Speaker, one copy with the Minority Leader and one copy
with | 4 | | the Clerk of the House of Representatives, one copy with the | 5 | | President,
one copy with the Minority Leader and one copy with | 6 | | the Secretary of the
Senate, one copy with the Legislative | 7 | | Research Unit, and such additional
copies
with the State | 8 | | Government Report Distribution Center for the General
Assembly | 9 | | as is required under paragraph (t) of Section 7 of the State
| 10 | | Library Act shall be deemed sufficient to comply with this | 11 | | Section.
| 12 | | Rulemaking authority to implement Public Act 95-1045, if | 13 | | any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | On and after July 1, 2012, the Department shall reduce any | 19 | | rate of reimbursement for services or other payments or alter | 20 | | any methodologies authorized by this Code to reduce any rate of | 21 | | reimbursement for services or other payments in accordance with | 22 | | Section 5-5e. | 23 | | Because kidney transplantation can be an appropriate, cost | 24 | | effective
alternative to renal dialysis when medically | 25 | | necessary and notwithstanding the provisions of Section 1-11 of | 26 | | this Code, beginning October 1, 2014, the Department shall |
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| 1 | | cover kidney transplantation for noncitizens with end-stage | 2 | | renal disease who are not eligible for comprehensive medical | 3 | | benefits, who meet the residency requirements of Section 5-3 of | 4 | | this Code, and who would otherwise meet the financial | 5 | | requirements of the appropriate class of eligible persons under | 6 | | Section 5-2 of this Code. To qualify for coverage of kidney | 7 | | transplantation, such person must be receiving emergency renal | 8 | | dialysis services covered by the Department. Providers under | 9 | | this Section shall be prior approved and certified by the | 10 | | Department to perform kidney transplantation and the services | 11 | | under this Section shall be limited to services associated with | 12 | | kidney transplantation. | 13 | | Notwithstanding any other provision of this Code to the | 14 | | contrary, on or after July 1, 2015, all FDA approved forms of | 15 | | medication assisted treatment prescribed for the treatment of | 16 | | alcohol dependence or treatment of opioid dependence shall be | 17 | | covered under both fee for service and managed care medical | 18 | | assistance programs for persons who are otherwise eligible for | 19 | | medical assistance under this Article and shall not be subject | 20 | | to any (1) utilization control, other than those established | 21 | | under the American Society of Addiction Medicine patient | 22 | | placement criteria,
(2) prior authorization mandate, or (3) | 23 | | lifetime restriction limit
mandate. | 24 | | On or after July 1, 2015, opioid antagonists prescribed for | 25 | | the treatment of an opioid overdose, including the medication | 26 | | product, administration devices, and any pharmacy fees related |
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| 1 | | to the dispensing and administration of the opioid antagonist, | 2 | | shall be covered under the medical assistance program for | 3 | | persons who are otherwise eligible for medical assistance under | 4 | | this Article. As used in this Section, "opioid antagonist" | 5 | | means a drug that binds to opioid receptors and blocks or | 6 | | inhibits the effect of opioids acting on those receptors, | 7 | | including, but not limited to, naloxone hydrochloride or any | 8 | | other similarly acting drug approved by the U.S. Food and Drug | 9 | | Administration. | 10 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | 11 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | 12 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | 13 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | 14 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff. | 15 | | 8-21-15; 99-480, eff. 9-9-15; revised 10-13-15.) | 16 | | (Text of Section after amendment by P.A. 99-407 ) | 17 | | Sec. 5-5. Medical services. The Illinois Department, by | 18 | | rule, shall
determine the quantity and quality of and the rate | 19 | | of reimbursement for the
medical assistance for which
payment | 20 | | will be authorized, and the medical services to be provided,
| 21 | | which may include all or part of the following: (1) inpatient | 22 | | hospital
services; (2) outpatient hospital services; (3) other | 23 | | laboratory and
X-ray services; (4) skilled nursing home | 24 | | services; (5) physicians'
services whether furnished in the | 25 | | office, the patient's home, a
hospital, a skilled nursing home, |
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| 1 | | or elsewhere; (6) medical care, or any
other type of remedial | 2 | | care furnished by licensed practitioners; (7)
home health care | 3 | | services; (8) private duty nursing service; (9) clinic
| 4 | | services; (10) dental services, including prevention and | 5 | | treatment of periodontal disease and dental caries disease for | 6 | | pregnant women, provided by an individual licensed to practice | 7 | | dentistry or dental surgery; for purposes of this item (10), | 8 | | "dental services" means diagnostic, preventive, or corrective | 9 | | procedures provided by or under the supervision of a dentist in | 10 | | the practice of his or her profession; (11) physical therapy | 11 | | and related
services; (12) prescribed drugs, dentures, and | 12 | | prosthetic devices; and
eyeglasses prescribed by a physician | 13 | | skilled in the diseases of the eye,
or by an optometrist, | 14 | | whichever the person may select; (13) other
diagnostic, | 15 | | screening, preventive, and rehabilitative services, including | 16 | | to ensure that the individual's need for intervention or | 17 | | treatment of mental disorders or substance use disorders or | 18 | | co-occurring mental health and substance use disorders is | 19 | | determined using a uniform screening, assessment, and | 20 | | evaluation process inclusive of criteria, for children and | 21 | | adults; for purposes of this item (13), a uniform screening, | 22 | | assessment, and evaluation process refers to a process that | 23 | | includes an appropriate evaluation and, as warranted, a | 24 | | referral; "uniform" does not mean the use of a singular | 25 | | instrument, tool, or process that all must utilize; (14)
| 26 | | transportation and such other expenses as may be necessary; |
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| 1 | | (15) medical
treatment of sexual assault survivors, as defined | 2 | | in
Section 1a of the Sexual Assault Survivors Emergency | 3 | | Treatment Act, for
injuries sustained as a result of the sexual | 4 | | assault, including
examinations and laboratory tests to | 5 | | discover evidence which may be used in
criminal proceedings | 6 | | arising from the sexual assault; (16) the
diagnosis and | 7 | | treatment of sickle cell anemia; and (17)
any other medical | 8 | | care, and any other type of remedial care recognized
under the | 9 | | laws of this State, but not including abortions, or induced
| 10 | | miscarriages or premature births, unless, in the opinion of a | 11 | | physician,
such procedures are necessary for the preservation | 12 | | of the life of the
woman seeking such treatment, or except an | 13 | | induced premature birth
intended to produce a live viable child | 14 | | and such procedure is necessary
for the health of the mother or | 15 | | her unborn child. The Illinois Department,
by rule, shall | 16 | | prohibit any physician from providing medical assistance
to | 17 | | anyone eligible therefor under this Code where such physician | 18 | | has been
found guilty of performing an abortion procedure in a | 19 | | wilful and wanton
manner upon a woman who was not pregnant at | 20 | | the time such abortion
procedure was performed. The term "any | 21 | | other type of remedial care" shall
include nursing care and | 22 | | nursing home service for persons who rely on
treatment by | 23 | | spiritual means alone through prayer for healing.
| 24 | | Notwithstanding any other provision of this Section, a | 25 | | comprehensive
tobacco use cessation program that includes | 26 | | purchasing prescription drugs or
prescription medical devices |
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| 1 | | approved by the Food and Drug Administration shall
be covered | 2 | | under the medical assistance
program under this Article for | 3 | | persons who are otherwise eligible for
assistance under this | 4 | | Article.
| 5 | | Notwithstanding any other provision of this Code, the | 6 | | Illinois
Department may not require, as a condition of payment | 7 | | for any laboratory
test authorized under this Article, that a | 8 | | physician's handwritten signature
appear on the laboratory | 9 | | test order form. The Illinois Department may,
however, impose | 10 | | other appropriate requirements regarding laboratory test
order | 11 | | documentation.
| 12 | | Upon receipt of federal approval of an amendment to the | 13 | | Illinois Title XIX State Plan for this purpose, the Department | 14 | | shall authorize the Chicago Public Schools (CPS) to procure a | 15 | | vendor or vendors to manufacture eyeglasses for individuals | 16 | | enrolled in a school within the CPS system. CPS shall ensure | 17 | | that its vendor or vendors are enrolled as providers in the | 18 | | medical assistance program and in any capitated Medicaid | 19 | | managed care entity (MCE) serving individuals enrolled in a | 20 | | school within the CPS system. Under any contract procured under | 21 | | this provision, the vendor or vendors must serve only | 22 | | individuals enrolled in a school within the CPS system. Claims | 23 | | for services provided by CPS's vendor or vendors to recipients | 24 | | of benefits in the medical assistance program under this Code, | 25 | | the Children's Health Insurance Program, or the Covering ALL | 26 | | KIDS Health Insurance Program shall be submitted to the |
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| 1 | | Department or the MCE in which the individual is enrolled for | 2 | | payment and shall be reimbursed at the Department's or the | 3 | | MCE's established rates or rate methodologies for eyeglasses. | 4 | | On and after July 1, 2012, the Department of Healthcare and | 5 | | Family Services may provide the following services to
persons
| 6 | | eligible for assistance under this Article who are | 7 | | participating in
education, training or employment programs | 8 | | operated by the Department of Human
Services as successor to | 9 | | the Department of Public Aid:
| 10 | | (1) dental services provided by or under the | 11 | | supervision of a dentist; and
| 12 | | (2) eyeglasses prescribed by a physician skilled in the | 13 | | diseases of the
eye, or by an optometrist, whichever the | 14 | | person may select.
| 15 | | Notwithstanding any other provision of this Code and | 16 | | subject to federal approval, the Department may adopt rules to | 17 | | allow a dentist who is volunteering his or her service at no | 18 | | cost to render dental services through an enrolled | 19 | | not-for-profit health clinic without the dentist personally | 20 | | enrolling as a participating provider in the medical assistance | 21 | | program. A not-for-profit health clinic shall include a public | 22 | | health clinic or Federally Qualified Health Center or other | 23 | | enrolled provider, as determined by the Department, through | 24 | | which dental services covered under this Section are performed. | 25 | | The Department shall establish a process for payment of claims | 26 | | for reimbursement for covered dental services rendered under |
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| 1 | | this provision. | 2 | | The Illinois Department, by rule, may distinguish and | 3 | | classify the
medical services to be provided only in accordance | 4 | | with the classes of
persons designated in Section 5-2.
| 5 | | The Department of Healthcare and Family Services must | 6 | | provide coverage and reimbursement for amino acid-based | 7 | | elemental formulas, regardless of delivery method, for the | 8 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 9 | | short bowel syndrome when the prescribing physician has issued | 10 | | a written order stating that the amino acid-based elemental | 11 | | formula is medically necessary.
| 12 | | The Illinois Department shall authorize the provision of, | 13 | | and shall
authorize payment for, screening by low-dose | 14 | | mammography for the presence of
occult breast cancer for women | 15 | | 35 years of age or older who are eligible
for medical | 16 | | assistance under this Article, as follows: | 17 | | (A) A baseline
mammogram for women 35 to 39 years of | 18 | | age.
| 19 | | (B) An annual mammogram for women 40 years of age or | 20 | | older. | 21 | | (C) A mammogram at the age and intervals considered | 22 | | medically necessary by the woman's health care provider for | 23 | | women under 40 years of age and having a family history of | 24 | | breast cancer, prior personal history of breast cancer, | 25 | | positive genetic testing, or other risk factors. | 26 | | (D) A comprehensive ultrasound screening of an entire |
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| 1 | | breast or breasts if a mammogram demonstrates | 2 | | heterogeneous or dense breast tissue, when medically | 3 | | necessary as determined by a physician licensed to practice | 4 | | medicine in all of its branches. | 5 | | (E) A screening MRI when medically necessary, as | 6 | | determined by a physician licensed to practice medicine in | 7 | | all of its branches. | 8 | | All screenings
shall
include a physical breast exam, | 9 | | instruction on self-examination and
information regarding the | 10 | | frequency of self-examination and its value as a
preventative | 11 | | tool. For purposes of this Section, "low-dose mammography" | 12 | | means
the x-ray examination of the breast using equipment | 13 | | dedicated specifically
for mammography, including the x-ray | 14 | | tube, filter, compression device,
and image receptor, with an | 15 | | average radiation exposure delivery
of less than one rad per | 16 | | breast for 2 views of an average size breast.
The term also | 17 | | includes digital mammography and includes breast | 18 | | tomosynthesis. As used in this Section, the term "breast | 19 | | tomosynthesis" means a radiologic procedure that involves the | 20 | | acquisition of projection images over the stationary breast to | 21 | | produce cross-sectional digital three-dimensional images of | 22 | | the breast.
| 23 | | On and after January 1, 2016, the Department shall ensure | 24 | | that all networks of care for adult clients of the Department | 25 | | include access to at least one breast imaging Center of Imaging | 26 | | Excellence as certified by the American College of Radiology. |
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| 1 | | On and after January 1, 2012, providers participating in a | 2 | | quality improvement program approved by the Department shall be | 3 | | reimbursed for screening and diagnostic mammography at the same | 4 | | rate as the Medicare program's rates, including the increased | 5 | | reimbursement for digital mammography. | 6 | | The Department shall convene an expert panel including | 7 | | representatives of hospitals, free-standing mammography | 8 | | facilities, and doctors, including radiologists, to establish | 9 | | quality standards for mammography. | 10 | | On and after January 1, 2017, providers participating in a | 11 | | breast cancer treatment quality improvement program approved | 12 | | by the Department shall be reimbursed for breast cancer | 13 | | treatment at a rate that is no lower than 95% of the Medicare | 14 | | program's rates for the data elements included in the breast | 15 | | cancer treatment quality program. | 16 | | The Department shall convene an expert panel, including | 17 | | representatives of hospitals, free standing breast cancer | 18 | | treatment centers, breast cancer quality organizations, and | 19 | | doctors, including breast surgeons, reconstructive breast | 20 | | surgeons, oncologists, and primary care providers to establish | 21 | | quality standards for breast cancer treatment. | 22 | | Subject to federal approval, the Department shall | 23 | | establish a rate methodology for mammography at federally | 24 | | qualified health centers and other encounter-rate clinics. | 25 | | These clinics or centers may also collaborate with other | 26 | | hospital-based mammography facilities. By January 1, 2016, the |
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| 1 | | Department shall report to the General Assembly on the status | 2 | | of the provision set forth in this paragraph. | 3 | | The Department shall establish a methodology to remind | 4 | | women who are age-appropriate for screening mammography, but | 5 | | who have not received a mammogram within the previous 18 | 6 | | months, of the importance and benefit of screening mammography. | 7 | | The Department shall work with experts in breast cancer | 8 | | outreach and patient navigation to optimize these reminders and | 9 | | shall establish a methodology for evaluating their | 10 | | effectiveness and modifying the methodology based on the | 11 | | evaluation. | 12 | | The Department shall establish a performance goal for | 13 | | primary care providers with respect to their female patients | 14 | | over age 40 receiving an annual mammogram. This performance | 15 | | goal shall be used to provide additional reimbursement in the | 16 | | form of a quality performance bonus to primary care providers | 17 | | who meet that goal. | 18 | | The Department shall devise a means of case-managing or | 19 | | patient navigation for beneficiaries diagnosed with breast | 20 | | cancer. This program shall initially operate as a pilot program | 21 | | in areas of the State with the highest incidence of mortality | 22 | | related to breast cancer. At least one pilot program site shall | 23 | | be in the metropolitan Chicago area and at least one site shall | 24 | | be outside the metropolitan Chicago area. On or after July 1, | 25 | | 2016, the pilot program shall be expanded to include one site | 26 | | in western Illinois, one site in southern Illinois, one site in |
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| 1 | | central Illinois, and 4 sites within metropolitan Chicago. An | 2 | | evaluation of the pilot program shall be carried out measuring | 3 | | health outcomes and cost of care for those served by the pilot | 4 | | program compared to similarly situated patients who are not | 5 | | served by the pilot program. | 6 | | The Department shall require all networks of care to | 7 | | develop a means either internally or by contract with experts | 8 | | in navigation and community outreach to navigate cancer | 9 | | patients to comprehensive care in a timely fashion. The | 10 | | Department shall require all networks of care to include access | 11 | | for patients diagnosed with cancer to at least one academic | 12 | | commission on cancer-accredited cancer program as an | 13 | | in-network covered benefit. | 14 | | Any medical or health care provider shall immediately | 15 | | recommend, to
any pregnant woman who is being provided prenatal | 16 | | services and is suspected
of drug abuse or is addicted as | 17 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 18 | | Act, referral to a local substance abuse treatment provider
| 19 | | licensed by the Department of Human Services or to a licensed
| 20 | | hospital which provides substance abuse treatment services. | 21 | | The Department of Healthcare and Family Services
shall assure | 22 | | coverage for the cost of treatment of the drug abuse or
| 23 | | addiction for pregnant recipients in accordance with the | 24 | | Illinois Medicaid
Program in conjunction with the Department of | 25 | | Human Services.
| 26 | | All medical providers providing medical assistance to |
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| 1 | | pregnant women
under this Code shall receive information from | 2 | | the Department on the
availability of services under the Drug | 3 | | Free Families with a Future or any
comparable program providing | 4 | | case management services for addicted women,
including | 5 | | information on appropriate referrals for other social services
| 6 | | that may be needed by addicted women in addition to treatment | 7 | | for addiction.
| 8 | | The Illinois Department, in cooperation with the | 9 | | Departments of Human
Services (as successor to the Department | 10 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 11 | | public awareness campaign, may
provide information concerning | 12 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 13 | | health care, and other pertinent programs directed at
reducing | 14 | | the number of drug-affected infants born to recipients of | 15 | | medical
assistance.
| 16 | | Neither the Department of Healthcare and Family Services | 17 | | nor the Department of Human
Services shall sanction the | 18 | | recipient solely on the basis of
her substance abuse.
| 19 | | The Illinois Department shall establish such regulations | 20 | | governing
the dispensing of health services under this Article | 21 | | as it shall deem
appropriate. The Department
should
seek the | 22 | | advice of formal professional advisory committees appointed by
| 23 | | the Director of the Illinois Department for the purpose of | 24 | | providing regular
advice on policy and administrative matters, | 25 | | information dissemination and
educational activities for | 26 | | medical and health care providers, and
consistency in |
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| 1 | | procedures to the Illinois Department.
| 2 | | The Illinois Department may develop and contract with | 3 | | Partnerships of
medical providers to arrange medical services | 4 | | for persons eligible under
Section 5-2 of this Code. | 5 | | Implementation of this Section may be by
demonstration projects | 6 | | in certain geographic areas. The Partnership shall
be | 7 | | represented by a sponsor organization. The Department, by rule, | 8 | | shall
develop qualifications for sponsors of Partnerships. | 9 | | Nothing in this
Section shall be construed to require that the | 10 | | sponsor organization be a
medical organization.
| 11 | | The sponsor must negotiate formal written contracts with | 12 | | medical
providers for physician services, inpatient and | 13 | | outpatient hospital care,
home health services, treatment for | 14 | | alcoholism and substance abuse, and
other services determined | 15 | | necessary by the Illinois Department by rule for
delivery by | 16 | | Partnerships. Physician services must include prenatal and
| 17 | | obstetrical care. The Illinois Department shall reimburse | 18 | | medical services
delivered by Partnership providers to clients | 19 | | in target areas according to
provisions of this Article and the | 20 | | Illinois Health Finance Reform Act,
except that:
| 21 | | (1) Physicians participating in a Partnership and | 22 | | providing certain
services, which shall be determined by | 23 | | the Illinois Department, to persons
in areas covered by the | 24 | | Partnership may receive an additional surcharge
for such | 25 | | services.
| 26 | | (2) The Department may elect to consider and negotiate |
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| 1 | | financial
incentives to encourage the development of | 2 | | Partnerships and the efficient
delivery of medical care.
| 3 | | (3) Persons receiving medical services through | 4 | | Partnerships may receive
medical and case management | 5 | | services above the level usually offered
through the | 6 | | medical assistance program.
| 7 | | Medical providers shall be required to meet certain | 8 | | qualifications to
participate in Partnerships to ensure the | 9 | | delivery of high quality medical
services. These | 10 | | qualifications shall be determined by rule of the Illinois
| 11 | | Department and may be higher than qualifications for | 12 | | participation in the
medical assistance program. Partnership | 13 | | sponsors may prescribe reasonable
additional qualifications | 14 | | for participation by medical providers, only with
the prior | 15 | | written approval of the Illinois Department.
| 16 | | Nothing in this Section shall limit the free choice of | 17 | | practitioners,
hospitals, and other providers of medical | 18 | | services by clients.
In order to ensure patient freedom of | 19 | | choice, the Illinois Department shall
immediately promulgate | 20 | | all rules and take all other necessary actions so that
provided | 21 | | services may be accessed from therapeutically certified | 22 | | optometrists
to the full extent of the Illinois Optometric | 23 | | Practice Act of 1987 without
discriminating between service | 24 | | providers.
| 25 | | The Department shall apply for a waiver from the United | 26 | | States Health
Care Financing Administration to allow for the |
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| 1 | | implementation of
Partnerships under this Section.
| 2 | | The Illinois Department shall require health care | 3 | | providers to maintain
records that document the medical care | 4 | | and services provided to recipients
of Medical Assistance under | 5 | | this Article. Such records must be retained for a period of not | 6 | | less than 6 years from the date of service or as provided by | 7 | | applicable State law, whichever period is longer, except that | 8 | | if an audit is initiated within the required retention period | 9 | | then the records must be retained until the audit is completed | 10 | | and every exception is resolved. The Illinois Department shall
| 11 | | require health care providers to make available, when | 12 | | authorized by the
patient, in writing, the medical records in a | 13 | | timely fashion to other
health care providers who are treating | 14 | | or serving persons eligible for
Medical Assistance under this | 15 | | Article. All dispensers of medical services
shall be required | 16 | | to maintain and retain business and professional records
| 17 | | sufficient to fully and accurately document the nature, scope, | 18 | | details and
receipt of the health care provided to persons | 19 | | eligible for medical
assistance under this Code, in accordance | 20 | | with regulations promulgated by
the Illinois Department. The | 21 | | rules and regulations shall require that proof
of the receipt | 22 | | of prescription drugs, dentures, prosthetic devices and
| 23 | | eyeglasses by eligible persons under this Section accompany | 24 | | each claim
for reimbursement submitted by the dispenser of such | 25 | | medical services.
No such claims for reimbursement shall be | 26 | | approved for payment by the Illinois
Department without such |
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| 1 | | proof of receipt, unless the Illinois Department
shall have put | 2 | | into effect and shall be operating a system of post-payment
| 3 | | audit and review which shall, on a sampling basis, be deemed | 4 | | adequate by
the Illinois Department to assure that such drugs, | 5 | | dentures, prosthetic
devices and eyeglasses for which payment | 6 | | is being made are actually being
received by eligible | 7 | | recipients. Within 90 days after September 16, 1984 ( the | 8 | | effective date of Public Act 83-1439)
this amendatory Act of | 9 | | 1984 , the Illinois Department shall establish a
current list of | 10 | | acquisition costs for all prosthetic devices and any
other | 11 | | items recognized as medical equipment and supplies | 12 | | reimbursable under
this Article and shall update such list on a | 13 | | quarterly basis, except that
the acquisition costs of all | 14 | | prescription drugs shall be updated no
less frequently than | 15 | | every 30 days as required by Section 5-5.12.
| 16 | | The rules and regulations of the Illinois Department shall | 17 | | require
that a written statement including the required opinion | 18 | | of a physician
shall accompany any claim for reimbursement for | 19 | | abortions, or induced
miscarriages or premature births. This | 20 | | statement shall indicate what
procedures were used in providing | 21 | | such medical services.
| 22 | | Notwithstanding any other law to the contrary, the Illinois | 23 | | Department shall, within 365 days after July 22, 2013 (the | 24 | | effective date of Public Act 98-104), establish procedures to | 25 | | permit skilled care facilities licensed under the Nursing Home | 26 | | Care Act to submit monthly billing claims for reimbursement |
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| 1 | | purposes. Following development of these procedures, the | 2 | | Department shall, by July 1, 2016, test the viability of the | 3 | | new system and implement any necessary operational or | 4 | | structural changes to its information technology platforms in | 5 | | order to allow for the direct acceptance and payment of nursing | 6 | | home claims. | 7 | | Notwithstanding any other law to the contrary, the Illinois | 8 | | Department shall, within 365 days after August 15, 2014 (the | 9 | | effective date of Public Act 98-963), establish procedures to | 10 | | permit ID/DD facilities licensed under the ID/DD Community Care | 11 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 12 | | monthly billing claims for reimbursement purposes. Following | 13 | | development of these procedures, the Department shall have an | 14 | | additional 365 days to test the viability of the new system and | 15 | | to ensure that any necessary operational or structural changes | 16 | | to its information technology platforms are implemented. | 17 | | The Illinois Department shall require all dispensers of | 18 | | medical
services, other than an individual practitioner or | 19 | | group of practitioners,
desiring to participate in the Medical | 20 | | Assistance program
established under this Article to disclose | 21 | | all financial, beneficial,
ownership, equity, surety or other | 22 | | interests in any and all firms,
corporations, partnerships, | 23 | | associations, business enterprises, joint
ventures, agencies, | 24 | | institutions or other legal entities providing any
form of | 25 | | health care services in this State under this Article.
| 26 | | The Illinois Department may require that all dispensers of |
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| 1 | | medical
services desiring to participate in the medical | 2 | | assistance program
established under this Article disclose, | 3 | | under such terms and conditions as
the Illinois Department may | 4 | | by rule establish, all inquiries from clients
and attorneys | 5 | | regarding medical bills paid by the Illinois Department, which
| 6 | | inquiries could indicate potential existence of claims or liens | 7 | | for the
Illinois Department.
| 8 | | Enrollment of a vendor
shall be
subject to a provisional | 9 | | period and shall be conditional for one year. During the period | 10 | | of conditional enrollment, the Department may
terminate the | 11 | | vendor's eligibility to participate in, or may disenroll the | 12 | | vendor from, the medical assistance
program without cause. | 13 | | Unless otherwise specified, such termination of eligibility or | 14 | | disenrollment is not subject to the
Department's hearing | 15 | | process.
However, a disenrolled vendor may reapply without | 16 | | penalty.
| 17 | | The Department has the discretion to limit the conditional | 18 | | enrollment period for vendors based upon category of risk of | 19 | | the vendor. | 20 | | Prior to enrollment and during the conditional enrollment | 21 | | period in the medical assistance program, all vendors shall be | 22 | | subject to enhanced oversight, screening, and review based on | 23 | | the risk of fraud, waste, and abuse that is posed by the | 24 | | category of risk of the vendor. The Illinois Department shall | 25 | | establish the procedures for oversight, screening, and review, | 26 | | which may include, but need not be limited to: criminal and |
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| 1 | | financial background checks; fingerprinting; license, | 2 | | certification, and authorization verifications; unscheduled or | 3 | | unannounced site visits; database checks; prepayment audit | 4 | | reviews; audits; payment caps; payment suspensions; and other | 5 | | screening as required by federal or State law. | 6 | | The Department shall define or specify the following: (i) | 7 | | by provider notice, the "category of risk of the vendor" for | 8 | | each type of vendor, which shall take into account the level of | 9 | | screening applicable to a particular category of vendor under | 10 | | federal law and regulations; (ii) by rule or provider notice, | 11 | | the maximum length of the conditional enrollment period for | 12 | | each category of risk of the vendor; and (iii) by rule, the | 13 | | hearing rights, if any, afforded to a vendor in each category | 14 | | of risk of the vendor that is terminated or disenrolled during | 15 | | the conditional enrollment period. | 16 | | To be eligible for payment consideration, a vendor's | 17 | | payment claim or bill, either as an initial claim or as a | 18 | | resubmitted claim following prior rejection, must be received | 19 | | by the Illinois Department, or its fiscal intermediary, no | 20 | | later than 180 days after the latest date on the claim on which | 21 | | medical goods or services were provided, with the following | 22 | | exceptions: | 23 | | (1) In the case of a provider whose enrollment is in | 24 | | process by the Illinois Department, the 180-day period | 25 | | shall not begin until the date on the written notice from | 26 | | the Illinois Department that the provider enrollment is |
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| 1 | | complete. | 2 | | (2) In the case of errors attributable to the Illinois | 3 | | Department or any of its claims processing intermediaries | 4 | | which result in an inability to receive, process, or | 5 | | adjudicate a claim, the 180-day period shall not begin | 6 | | until the provider has been notified of the error. | 7 | | (3) In the case of a provider for whom the Illinois | 8 | | Department initiates the monthly billing process. | 9 | | (4) In the case of a provider operated by a unit of | 10 | | local government with a population exceeding 3,000,000 | 11 | | when local government funds finance federal participation | 12 | | for claims payments. | 13 | | For claims for services rendered during a period for which | 14 | | a recipient received retroactive eligibility, claims must be | 15 | | filed within 180 days after the Department determines the | 16 | | applicant is eligible. For claims for which the Illinois | 17 | | Department is not the primary payer, claims must be submitted | 18 | | to the Illinois Department within 180 days after the final | 19 | | adjudication by the primary payer. | 20 | | In the case of long term care facilities, within 5 days of | 21 | | receipt by the facility of required prescreening information, | 22 | | data for new admissions shall be entered into the Medical | 23 | | Electronic Data Interchange (MEDI) or the Recipient | 24 | | Eligibility Verification (REV) System or successor system, and | 25 | | within 15 days of receipt by the facility of required | 26 | | prescreening information, admission documents shall be |
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| 1 | | submitted through MEDI or REV or shall be submitted directly to | 2 | | the Department of Human Services using required admission | 3 | | forms. Effective September
1, 2014, admission documents, | 4 | | including all prescreening
information, must be submitted | 5 | | through MEDI or REV. Confirmation numbers assigned to an | 6 | | accepted transaction shall be retained by a facility to verify | 7 | | timely submittal. Once an admission transaction has been | 8 | | completed, all resubmitted claims following prior rejection | 9 | | are subject to receipt no later than 180 days after the | 10 | | admission transaction has been completed. | 11 | | Claims that are not submitted and received in compliance | 12 | | with the foregoing requirements shall not be eligible for | 13 | | payment under the medical assistance program, and the State | 14 | | shall have no liability for payment of those claims. | 15 | | To the extent consistent with applicable information and | 16 | | privacy, security, and disclosure laws, State and federal | 17 | | agencies and departments shall provide the Illinois Department | 18 | | access to confidential and other information and data necessary | 19 | | to perform eligibility and payment verifications and other | 20 | | Illinois Department functions. This includes, but is not | 21 | | limited to: information pertaining to licensure; | 22 | | certification; earnings; immigration status; citizenship; wage | 23 | | reporting; unearned and earned income; pension income; | 24 | | employment; supplemental security income; social security | 25 | | numbers; National Provider Identifier (NPI) numbers; the | 26 | | National Practitioner Data Bank (NPDB); program and agency |
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| 1 | | exclusions; taxpayer identification numbers; tax delinquency; | 2 | | corporate information; and death records. | 3 | | The Illinois Department shall enter into agreements with | 4 | | State agencies and departments, and is authorized to enter into | 5 | | agreements with federal agencies and departments, under which | 6 | | such agencies and departments shall share data necessary for | 7 | | medical assistance program integrity functions and oversight. | 8 | | The Illinois Department shall develop, in cooperation with | 9 | | other State departments and agencies, and in compliance with | 10 | | applicable federal laws and regulations, appropriate and | 11 | | effective methods to share such data. At a minimum, and to the | 12 | | extent necessary to provide data sharing, the Illinois | 13 | | Department shall enter into agreements with State agencies and | 14 | | departments, and is authorized to enter into agreements with | 15 | | federal agencies and departments, including but not limited to: | 16 | | the Secretary of State; the Department of Revenue; the | 17 | | Department of Public Health; the Department of Human Services; | 18 | | and the Department of Financial and Professional Regulation. | 19 | | Beginning in fiscal year 2013, the Illinois Department | 20 | | shall set forth a request for information to identify the | 21 | | benefits of a pre-payment, post-adjudication, and post-edit | 22 | | claims system with the goals of streamlining claims processing | 23 | | and provider reimbursement, reducing the number of pending or | 24 | | rejected claims, and helping to ensure a more transparent | 25 | | adjudication process through the utilization of: (i) provider | 26 | | data verification and provider screening technology; and (ii) |
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| 1 | | clinical code editing; and (iii) pre-pay, pre- or | 2 | | post-adjudicated predictive modeling with an integrated case | 3 | | management system with link analysis. Such a request for | 4 | | information shall not be considered as a request for proposal | 5 | | or as an obligation on the part of the Illinois Department to | 6 | | take any action or acquire any products or services. | 7 | | The Illinois Department shall establish policies, | 8 | | procedures,
standards and criteria by rule for the acquisition, | 9 | | repair and replacement
of orthotic and prosthetic devices and | 10 | | durable medical equipment. Such
rules shall provide, but not be | 11 | | limited to, the following services: (1)
immediate repair or | 12 | | replacement of such devices by recipients; and (2) rental, | 13 | | lease, purchase or lease-purchase of
durable medical equipment | 14 | | in a cost-effective manner, taking into
consideration the | 15 | | recipient's medical prognosis, the extent of the
recipient's | 16 | | needs, and the requirements and costs for maintaining such
| 17 | | equipment. Subject to prior approval, such rules shall enable a | 18 | | recipient to temporarily acquire and
use alternative or | 19 | | substitute devices or equipment pending repairs or
| 20 | | replacements of any device or equipment previously authorized | 21 | | for such
recipient by the Department. Notwithstanding any | 22 | | provision of Section 5-5f to the contrary, the Department may, | 23 | | by rule, exempt certain replacement wheelchair parts from prior | 24 | | approval and determine the wholesale price by methods other | 25 | | than actual acquisition costs.
| 26 | | The Department shall require, by rule, all providers of |
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| 1 | | durable medical equipment to be accredited by an accreditation | 2 | | organization approved by the federal Centers for Medicare and | 3 | | Medicaid Services and recognized by the Department in order to | 4 | | bill the Department for providing durable medical equipment to | 5 | | recipients. No later than 15 months after the effective date of | 6 | | the rule adopted pursuant to this paragraph, all providers must | 7 | | meet the accreditation requirement. | 8 | | The Department shall execute, relative to the nursing home | 9 | | prescreening
project, written inter-agency agreements with the | 10 | | Department of Human
Services and the Department on Aging, to | 11 | | effect the following: (i) intake
procedures and common | 12 | | eligibility criteria for those persons who are receiving
| 13 | | non-institutional services; and (ii) the establishment and | 14 | | development of
non-institutional services in areas of the State | 15 | | where they are not currently
available or are undeveloped; and | 16 | | (iii) notwithstanding any other provision of law, subject to | 17 | | federal approval, on and after July 1, 2012, an increase in the | 18 | | determination of need (DON) scores from 29 to 37 for applicants | 19 | | for institutional and home and community-based long term care; | 20 | | if and only if federal approval is not granted, the Department | 21 | | may, in conjunction with other affected agencies, implement | 22 | | utilization controls or changes in benefit packages to | 23 | | effectuate a similar savings amount for this population; and | 24 | | (iv) no later than July 1, 2013, minimum level of care | 25 | | eligibility criteria for institutional and home and | 26 | | community-based long term care; and (v) no later than October |
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| 1 | | 1, 2013, establish procedures to permit long term care | 2 | | providers access to eligibility scores for individuals with an | 3 | | admission date who are seeking or receiving services from the | 4 | | long term care provider. In order to select the minimum level | 5 | | of care eligibility criteria, the Governor shall establish a | 6 | | workgroup that includes affected agency representatives and | 7 | | stakeholders representing the institutional and home and | 8 | | community-based long term care interests. This Section shall | 9 | | not restrict the Department from implementing lower level of | 10 | | care eligibility criteria for community-based services in | 11 | | circumstances where federal approval has been granted.
| 12 | | The Illinois Department shall develop and operate, in | 13 | | cooperation
with other State Departments and agencies and in | 14 | | compliance with
applicable federal laws and regulations, | 15 | | appropriate and effective
systems of health care evaluation and | 16 | | programs for monitoring of
utilization of health care services | 17 | | and facilities, as it affects
persons eligible for medical | 18 | | assistance under this Code.
| 19 | | The Illinois Department shall report annually to the | 20 | | General Assembly,
no later than the second Friday in April of | 21 | | 1979 and each year
thereafter, in regard to:
| 22 | | (a) actual statistics and trends in utilization of | 23 | | medical services by
public aid recipients;
| 24 | | (b) actual statistics and trends in the provision of | 25 | | the various medical
services by medical vendors;
| 26 | | (c) current rate structures and proposed changes in |
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| 1 | | those rate structures
for the various medical vendors; and
| 2 | | (d) efforts at utilization review and control by the | 3 | | Illinois Department.
| 4 | | The period covered by each report shall be the 3 years | 5 | | ending on the June
30 prior to the report. The report shall | 6 | | include suggested legislation
for consideration by the General | 7 | | Assembly. The filing of one copy of the
report with the | 8 | | Speaker, one copy with the Minority Leader and one copy
with | 9 | | the Clerk of the House of Representatives, one copy with the | 10 | | President,
one copy with the Minority Leader and one copy with | 11 | | the Secretary of the
Senate, one copy with the Legislative | 12 | | Research Unit, and such additional
copies
with the State | 13 | | Government Report Distribution Center for the General
Assembly | 14 | | as is required under paragraph (t) of Section 7 of the State
| 15 | | Library Act shall be deemed sufficient to comply with this | 16 | | Section.
| 17 | | Rulemaking authority to implement Public Act 95-1045, if | 18 | | any, is conditioned on the rules being adopted in accordance | 19 | | with all provisions of the Illinois Administrative Procedure | 20 | | Act and all rules and procedures of the Joint Committee on | 21 | | Administrative Rules; any purported rule not so adopted, for | 22 | | whatever reason, is unauthorized. | 23 | | On and after July 1, 2012, the Department shall reduce any | 24 | | rate of reimbursement for services or other payments or alter | 25 | | any methodologies authorized by this Code to reduce any rate of | 26 | | reimbursement for services or other payments in accordance with |
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| 1 | | Section 5-5e. | 2 | | Because kidney transplantation can be an appropriate, cost | 3 | | effective
alternative to renal dialysis when medically | 4 | | necessary and notwithstanding the provisions of Section 1-11 of | 5 | | this Code, beginning October 1, 2014, the Department shall | 6 | | cover kidney transplantation for noncitizens with end-stage | 7 | | renal disease who are not eligible for comprehensive medical | 8 | | benefits, who meet the residency requirements of Section 5-3 of | 9 | | this Code, and who would otherwise meet the financial | 10 | | requirements of the appropriate class of eligible persons under | 11 | | Section 5-2 of this Code. To qualify for coverage of kidney | 12 | | transplantation, such person must be receiving emergency renal | 13 | | dialysis services covered by the Department. Providers under | 14 | | this Section shall be prior approved and certified by the | 15 | | Department to perform kidney transplantation and the services | 16 | | under this Section shall be limited to services associated with | 17 | | kidney transplantation. | 18 | | Notwithstanding any other provision of this Code to the | 19 | | contrary, on or after July 1, 2015, all FDA approved forms of | 20 | | medication assisted treatment prescribed for the treatment of | 21 | | alcohol dependence or treatment of opioid dependence shall be | 22 | | covered under both fee for service and managed care medical | 23 | | assistance programs for persons who are otherwise eligible for | 24 | | medical assistance under this Article and shall not be subject | 25 | | to any (1) utilization control, other than those established | 26 | | under the American Society of Addiction Medicine patient |
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| 1 | | placement criteria,
(2) prior authorization mandate, or (3) | 2 | | lifetime restriction limit
mandate. | 3 | | On or after July 1, 2015, opioid antagonists prescribed for | 4 | | the treatment of an opioid overdose, including the medication | 5 | | product, administration devices, and any pharmacy fees related | 6 | | to the dispensing and administration of the opioid antagonist, | 7 | | shall be covered under the medical assistance program for | 8 | | persons who are otherwise eligible for medical assistance under | 9 | | this Article. As used in this Section, "opioid antagonist" | 10 | | means a drug that binds to opioid receptors and blocks or | 11 | | inhibits the effect of opioids acting on those receptors, | 12 | | including, but not limited to, naloxone hydrochloride or any | 13 | | other similarly acting drug approved by the U.S. Food and Drug | 14 | | Administration. | 15 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | 16 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | 17 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | 18 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | 19 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section | 20 | | 99 of P.A. 99-407 for its effective date); 99-433, eff. | 21 | | 8-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
| 22 | | Section 95. No acceleration or delay. Where this Act makes | 23 | | changes in a statute that is represented in this Act by text | 24 | | that is not yet or no longer in effect (for example, a Section | 25 | | represented by multiple versions), the use of that text does |
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| 1 | | not accelerate or delay the taking effect of (i) the changes | 2 | | made by this Act or (ii) provisions derived from any other | 3 | | Public Act.".
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