SB0420enr 99TH GENERAL ASSEMBLY



 


 
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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
 
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    (Text of Section before amendment by P.A. 99-407)
8    Sec. 5-5. Medical services. The Illinois Department, by
9rule, shall determine the quantity and quality of and the rate
10of reimbursement for the medical assistance for which payment
11will be authorized, and the medical services to be provided,
12which may include all or part of the following: (1) inpatient
13hospital services; (2) outpatient hospital services; (3) other
14laboratory and X-ray services; (4) skilled nursing home
15services; (5) physicians' services whether furnished in the
16office, the patient's home, a hospital, a skilled nursing home,
17or elsewhere; (6) medical care, or any other type of remedial
18care furnished by licensed practitioners; (7) home health care
19services; (8) private duty nursing service; (9) clinic
20services; (10) dental services, including prevention and
21treatment of periodontal disease and dental caries disease for
22pregnant women, provided by an individual licensed to practice
23dentistry or dental surgery; for purposes of this item (10),

 

 

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

 

 

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

 

 

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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
4documentation.
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured under
14this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare and
24Family Services may provide the following services to persons
25eligible for assistance under this Article who are
26participating in education, training or employment programs

 

 

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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    Notwithstanding any other provision of this Code and
9subject to federal approval, the Department may adopt rules to
10allow a dentist who is volunteering his or her service at no
11cost to render dental services through an enrolled
12not-for-profit health clinic without the dentist personally
13enrolling as a participating provider in the medical assistance
14program. A not-for-profit health clinic shall include a public
15health clinic or Federally Qualified Health Center or other
16enrolled provider, as determined by the Department, through
17which dental services covered under this Section are performed.
18The Department shall establish a process for payment of claims
19for reimbursement for covered dental services rendered under
20this provision.
21    The Illinois Department, by rule, may distinguish and
22classify the medical services to be provided only in accordance
23with the classes of persons designated in Section 5-2.
24    The Department of Healthcare and Family Services must
25provide coverage and reimbursement for amino acid-based
26elemental formulas, regardless of delivery method, for the

 

 

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1diagnosis and treatment of (i) eosinophilic disorders and (ii)
2short bowel syndrome when the prescribing physician has issued
3a written order stating that the amino acid-based elemental
4formula is medically necessary.
5    The Illinois Department shall authorize the provision of,
6and shall authorize payment for, screening by low-dose
7mammography for the presence of occult breast cancer for women
835 years of age or older who are eligible for medical
9assistance under this Article, as follows:
10        (A) A baseline mammogram for women 35 to 39 years of
11    age.
12        (B) An annual mammogram for women 40 years of age or
13    older.
14        (C) A mammogram at the age and intervals considered
15    medically necessary by the woman's health care provider for
16    women under 40 years of age and having a family history of
17    breast cancer, prior personal history of breast cancer,
18    positive genetic testing, or other risk factors.
19        (D) A comprehensive ultrasound screening of an entire
20    breast or breasts if a mammogram demonstrates
21    heterogeneous or dense breast tissue, when medically
22    necessary as determined by a physician licensed to practice
23    medicine in all of its branches.
24        (E) A screening MRI when medically necessary, as
25    determined by a physician licensed to practice medicine in
26    all of its branches.

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography.
11    On and after January 1, 2016, the Department shall ensure
12that all networks of care for adult clients of the Department
13include access to at least one breast imaging Center of Imaging
14Excellence as certified by the American College of Radiology.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20    The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards for mammography.
24    On and after January 1, 2017, providers participating in a
25breast cancer treatment quality improvement program approved
26by the Department shall be reimbursed for breast cancer

 

 

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1treatment at a rate that is no lower than 95% of the Medicare
2program's rates for the data elements included in the breast
3cancer treatment quality program.
4    The Department shall convene an expert panel, including
5representatives of hospitals, free standing breast cancer
6treatment centers, breast cancer quality organizations, and
7doctors, including breast surgeons, reconstructive breast
8surgeons, oncologists, and primary care providers to establish
9quality standards for breast cancer treatment.
10    Subject to federal approval, the Department shall
11establish a rate methodology for mammography at federally
12qualified health centers and other encounter-rate clinics.
13These clinics or centers may also collaborate with other
14hospital-based mammography facilities. By January 1, 2016, the
15Department shall report to the General Assembly on the status
16of the provision set forth in this paragraph.
17    The Department shall establish a methodology to remind
18women who are age-appropriate for screening mammography, but
19who have not received a mammogram within the previous 18
20months, of the importance and benefit of screening mammography.
21The Department shall work with experts in breast cancer
22outreach and patient navigation to optimize these reminders and
23shall establish a methodology for evaluating their
24effectiveness and modifying the methodology based on the
25evaluation.
26    The Department shall establish a performance goal for

 

 

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1primary care providers with respect to their female patients
2over age 40 receiving an annual mammogram. This performance
3goal shall be used to provide additional reimbursement in the
4form of a quality performance bonus to primary care providers
5who meet that goal.
6    The Department shall devise a means of case-managing or
7patient navigation for beneficiaries diagnosed with breast
8cancer. This program shall initially operate as a pilot program
9in areas of the State with the highest incidence of mortality
10related to breast cancer. At least one pilot program site shall
11be in the metropolitan Chicago area and at least one site shall
12be outside the metropolitan Chicago area. On or after July 1,
132016, the pilot program shall be expanded to include one site
14in western Illinois, one site in southern Illinois, one site in
15central Illinois, and 4 sites within metropolitan Chicago. An
16evaluation of the pilot program shall be carried out measuring
17health outcomes and cost of care for those served by the pilot
18program compared to similarly situated patients who are not
19served by the pilot program.
20    The Department shall require all networks of care to
21develop a means either internally or by contract with experts
22in navigation and community outreach to navigate cancer
23patients to comprehensive care in a timely fashion. The
24Department shall require all networks of care to include access
25for patients diagnosed with cancer to at least one academic
26commission on cancer-accredited cancer program as an

 

 

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1in-network covered benefit.
2    Any medical or health care provider shall immediately
3recommend, to any pregnant woman who is being provided prenatal
4services and is suspected of drug abuse or is addicted as
5defined in the Alcoholism and Other Drug Abuse and Dependency
6Act, referral to a local substance abuse treatment provider
7licensed by the Department of Human Services or to a licensed
8hospital which provides substance abuse treatment services.
9The Department of Healthcare and Family Services shall assure
10coverage for the cost of treatment of the drug abuse or
11addiction for pregnant recipients in accordance with the
12Illinois Medicaid Program in conjunction with the Department of
13Human Services.
14    All medical providers providing medical assistance to
15pregnant women under this Code shall receive information from
16the Department on the availability of services under the Drug
17Free Families with a Future or any comparable program providing
18case management services for addicted women, including
19information on appropriate referrals for other social services
20that may be needed by addicted women in addition to treatment
21for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through a
25public awareness campaign, may provide information concerning
26treatment for alcoholism and drug abuse and addiction, prenatal

 

 

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

 

 

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

 

 

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

 

 

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1timely fashion to other health care providers who are treating
2or serving persons eligible for Medical Assistance under this
3Article. All dispensers of medical services shall be required
4to maintain and retain business and professional records
5sufficient to fully and accurately document the nature, scope,
6details and receipt of the health care provided to persons
7eligible for medical assistance under this Code, in accordance
8with regulations promulgated by the Illinois Department. The
9rules and regulations shall require that proof of the receipt
10of prescription drugs, dentures, prosthetic devices and
11eyeglasses by eligible persons under this Section accompany
12each claim for reimbursement submitted by the dispenser of such
13medical services. No such claims for reimbursement shall be
14approved for payment by the Illinois Department without such
15proof of receipt, unless the Illinois Department shall have put
16into effect and shall be operating a system of post-payment
17audit and review which shall, on a sampling basis, be deemed
18adequate by the Illinois Department to assure that such drugs,
19dentures, prosthetic devices and eyeglasses for which payment
20is being made are actually being received by eligible
21recipients. Within 90 days after September 16, 1984 (the
22effective date of Public Act 83-1439) this amendatory Act of
231984, the Illinois Department shall establish a current list of
24acquisition costs for all prosthetic devices and any other
25items recognized as medical equipment and supplies
26reimbursable under this Article and shall update such list on a

 

 

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1quarterly basis, except that the acquisition costs of all
2prescription drugs shall be updated no less frequently than
3every 30 days as required by Section 5-5.12.
4    The rules and regulations of the Illinois Department shall
5require that a written statement including the required opinion
6of a physician shall accompany any claim for reimbursement for
7abortions, or induced miscarriages or premature births. This
8statement shall indicate what procedures were used in providing
9such medical services.
10    Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after July 22, 2013 (the
12effective date of Public Act 98-104), establish procedures to
13permit skilled care facilities licensed under the Nursing Home
14Care Act to submit monthly billing claims for reimbursement
15purposes. Following development of these procedures, the
16Department shall, by July 1, 2016, test the viability of the
17new system and implement any necessary operational or
18structural changes to its information technology platforms in
19order to allow for the direct acceptance and payment of nursing
20home claims.
21    Notwithstanding any other law to the contrary, the Illinois
22Department shall, within 365 days after August 15, 2014 (the
23effective date of Public Act 98-963), establish procedures to
24permit ID/DD facilities licensed under the ID/DD Community Care
25Act and MC/DD facilities licensed under the MC/DD Act to submit
26monthly billing claims for reimbursement purposes. Following

 

 

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1development of these procedures, the Department shall have an
2additional 365 days to test the viability of the new system and
3to ensure that any necessary operational or structural changes
4to its information technology platforms are implemented.
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.

 

 

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1Unless otherwise specified, such termination of eligibility or
2disenrollment is not subject to the Department's hearing
3process. However, a disenrolled vendor may reapply without
4penalty.
5    The Department has the discretion to limit the conditional
6enrollment period for vendors based upon category of risk of
7the vendor.
8    Prior to enrollment and during the conditional enrollment
9period in the medical assistance program, all vendors shall be
10subject to enhanced oversight, screening, and review based on
11the risk of fraud, waste, and abuse that is posed by the
12category of risk of the vendor. The Illinois Department shall
13establish the procedures for oversight, screening, and review,
14which may include, but need not be limited to: criminal and
15financial background checks; fingerprinting; license,
16certification, and authorization verifications; unscheduled or
17unannounced site visits; database checks; prepayment audit
18reviews; audits; payment caps; payment suspensions; and other
19screening as required by federal or State law.
20    The Department shall define or specify the following: (i)
21by provider notice, the "category of risk of the vendor" for
22each type of vendor, which shall take into account the level of
23screening applicable to a particular category of vendor under
24federal law and regulations; (ii) by rule or provider notice,
25the maximum length of the conditional enrollment period for
26each category of risk of the vendor; and (iii) by rule, the

 

 

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1hearing rights, if any, afforded to a vendor in each category
2of risk of the vendor that is terminated or disenrolled during
3the conditional enrollment period.
4    To be eligible for payment consideration, a vendor's
5payment claim or bill, either as an initial claim or as a
6resubmitted claim following prior rejection, must be received
7by the Illinois Department, or its fiscal intermediary, no
8later than 180 days after the latest date on the claim on which
9medical goods or services were provided, with the following
10exceptions:
11        (1) In the case of a provider whose enrollment is in
12    process by the Illinois Department, the 180-day period
13    shall not begin until the date on the written notice from
14    the Illinois Department that the provider enrollment is
15    complete.
16        (2) In the case of errors attributable to the Illinois
17    Department or any of its claims processing intermediaries
18    which result in an inability to receive, process, or
19    adjudicate a claim, the 180-day period shall not begin
20    until the provider has been notified of the error.
21        (3) In the case of a provider for whom the Illinois
22    Department initiates the monthly billing process.
23        (4) In the case of a provider operated by a unit of
24    local government with a population exceeding 3,000,000
25    when local government funds finance federal participation
26    for claims payments.

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the State
5where they are not currently available or are undeveloped; and
6(iii) notwithstanding any other provision of law, subject to
7federal approval, on and after July 1, 2012, an increase in the
8determination of need (DON) scores from 29 to 37 for applicants
9for institutional and home and community-based long term care;
10if and only if federal approval is not granted, the Department
11may, in conjunction with other affected agencies, implement
12utilization controls or changes in benefit packages to
13effectuate a similar savings amount for this population; and
14(iv) no later than July 1, 2013, minimum level of care
15eligibility criteria for institutional and home and
16community-based long term care; and (v) no later than October
171, 2013, establish procedures to permit long term care
18providers access to eligibility scores for individuals with an
19admission date who are seeking or receiving services from the
20long term care provider. In order to select the minimum level
21of care eligibility criteria, the Governor shall establish a
22workgroup that includes affected agency representatives and
23stakeholders representing the institutional and home and
24community-based long term care interests. This Section shall
25not restrict the Department from implementing lower level of
26care eligibility criteria for community-based services in

 

 

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1circumstances where federal approval has been granted.
2    The Illinois Department shall develop and operate, in
3cooperation with other State Departments and agencies and in
4compliance with applicable federal laws and regulations,
5appropriate and effective systems of health care evaluation and
6programs for monitoring of utilization of health care services
7and facilities, as it affects persons eligible for medical
8assistance under this Code.
9    The Illinois Department shall report annually to the
10General Assembly, no later than the second Friday in April of
111979 and each year thereafter, in regard to:
12        (a) actual statistics and trends in utilization of
13    medical services by public aid recipients;
14        (b) actual statistics and trends in the provision of
15    the various medical services by medical vendors;
16        (c) current rate structures and proposed changes in
17    those rate structures for the various medical vendors; and
18        (d) efforts at utilization review and control by the
19    Illinois Department.
20    The period covered by each report shall be the 3 years
21ending on the June 30 prior to the report. The report shall
22include suggested legislation for consideration by the General
23Assembly. The filing of one copy of the report with the
24Speaker, one copy with the Minority Leader and one copy with
25the Clerk of the House of Representatives, one copy with the
26President, one copy with the Minority Leader and one copy with

 

 

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

 

 

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

 

 

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1inhibits the effect of opioids acting on those receptors,
2including, but not limited to, naloxone hydrochloride or any
3other similarly acting drug approved by the U.S. Food and Drug
4Administration.
5(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
698-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
78-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
8eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
999-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
108-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
11    (Text of Section after amendment by P.A. 99-407)
12    Sec. 5-5. Medical services. The Illinois Department, by
13rule, shall determine the quantity and quality of and the rate
14of reimbursement for the medical assistance for which payment
15will be authorized, and the medical services to be provided,
16which may include all or part of the following: (1) inpatient
17hospital services; (2) outpatient hospital services; (3) other
18laboratory and X-ray services; (4) skilled nursing home
19services; (5) physicians' services whether furnished in the
20office, the patient's home, a hospital, a skilled nursing home,
21or elsewhere; (6) medical care, or any other type of remedial
22care furnished by licensed practitioners; (7) home health care
23services; (8) private duty nursing service; (9) clinic
24services; (10) dental services, including prevention and
25treatment of periodontal disease and dental caries disease for

 

 

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

 

 

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

 

 

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1Illinois Department may not require, as a condition of payment
2for any laboratory test authorized under this Article, that a
3physician's handwritten signature appear on the laboratory
4test order form. The Illinois Department may, however, impose
5other appropriate requirements regarding laboratory test order
6documentation.
7    Upon receipt of federal approval of an amendment to the
8Illinois Title XIX State Plan for this purpose, the Department
9shall authorize the Chicago Public Schools (CPS) to procure a
10vendor or vendors to manufacture eyeglasses for individuals
11enrolled in a school within the CPS system. CPS shall ensure
12that its vendor or vendors are enrolled as providers in the
13medical assistance program and in any capitated Medicaid
14managed care entity (MCE) serving individuals enrolled in a
15school within the CPS system. Under any contract procured under
16this provision, the vendor or vendors must serve only
17individuals enrolled in a school within the CPS system. Claims
18for services provided by CPS's vendor or vendors to recipients
19of benefits in the medical assistance program under this Code,
20the Children's Health Insurance Program, or the Covering ALL
21KIDS Health Insurance Program shall be submitted to the
22Department or the MCE in which the individual is enrolled for
23payment and shall be reimbursed at the Department's or the
24MCE's established rates or rate methodologies for eyeglasses.
25    On and after July 1, 2012, the Department of Healthcare and
26Family Services may provide the following services to persons

 

 

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

 

 

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1provide coverage and reimbursement for amino acid-based
2elemental formulas, regardless of delivery method, for the
3diagnosis and treatment of (i) eosinophilic disorders and (ii)
4short bowel syndrome when the prescribing physician has issued
5a written order stating that the amino acid-based elemental
6formula is medically necessary.
7    The Illinois Department shall authorize the provision of,
8and shall authorize payment for, screening by low-dose
9mammography for the presence of occult breast cancer for women
1035 years of age or older who are eligible for medical
11assistance under this Article, as follows:
12        (A) A baseline mammogram for women 35 to 39 years of
13    age.
14        (B) An annual mammogram for women 40 years of age or
15    older.
16        (C) A mammogram at the age and intervals considered
17    medically necessary by the woman's health care provider for
18    women under 40 years of age and having a family history of
19    breast cancer, prior personal history of breast cancer,
20    positive genetic testing, or other risk factors.
21        (D) A comprehensive ultrasound screening of an entire
22    breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue, when medically
24    necessary as determined by a physician licensed to practice
25    medicine in all of its branches.
26        (E) A screening MRI when medically necessary, as

 

 

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1    determined by a physician licensed to practice medicine in
2    all of its branches.
3    All screenings shall include a physical breast exam,
4instruction on self-examination and information regarding the
5frequency of self-examination and its value as a preventative
6tool. For purposes of this Section, "low-dose mammography"
7means the x-ray examination of the breast using equipment
8dedicated specifically for mammography, including the x-ray
9tube, filter, compression device, and image receptor, with an
10average radiation exposure delivery of less than one rad per
11breast for 2 views of an average size breast. The term also
12includes digital mammography and includes breast
13tomosynthesis. As used in this Section, the term "breast
14tomosynthesis" means a radiologic procedure that involves the
15acquisition of projection images over the stationary breast to
16produce cross-sectional digital three-dimensional images of
17the breast.
18    On and after January 1, 2016, the Department shall ensure
19that all networks of care for adult clients of the Department
20include access to at least one breast imaging Center of Imaging
21Excellence as certified by the American College of Radiology.
22    On and after January 1, 2012, providers participating in a
23quality improvement program approved by the Department shall be
24reimbursed for screening and diagnostic mammography at the same
25rate as the Medicare program's rates, including the increased
26reimbursement for digital mammography.

 

 

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1    The Department shall convene an expert panel including
2representatives of hospitals, free-standing mammography
3facilities, and doctors, including radiologists, to establish
4quality standards for mammography.
5    On and after January 1, 2017, providers participating in a
6breast cancer treatment quality improvement program approved
7by the Department shall be reimbursed for breast cancer
8treatment at a rate that is no lower than 95% of the Medicare
9program's rates for the data elements included in the breast
10cancer treatment quality program.
11    The Department shall convene an expert panel, including
12representatives of hospitals, free standing breast cancer
13treatment centers, breast cancer quality organizations, and
14doctors, including breast surgeons, reconstructive breast
15surgeons, oncologists, and primary care providers to establish
16quality standards for breast cancer treatment.
17    Subject to federal approval, the Department shall
18establish a rate methodology for mammography at federally
19qualified health centers and other encounter-rate clinics.
20These clinics or centers may also collaborate with other
21hospital-based mammography facilities. By January 1, 2016, the
22Department shall report to the General Assembly on the status
23of the provision set forth in this paragraph.
24    The Department shall establish a methodology to remind
25women who are age-appropriate for screening mammography, but
26who have not received a mammogram within the previous 18

 

 

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1months, of the importance and benefit of screening mammography.
2The Department shall work with experts in breast cancer
3outreach and patient navigation to optimize these reminders and
4shall establish a methodology for evaluating their
5effectiveness and modifying the methodology based on the
6evaluation.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. On or after July 1,
202016, the pilot program shall be expanded to include one site
21in western Illinois, one site in southern Illinois, one site in
22central Illinois, and 4 sites within metropolitan Chicago. An
23evaluation of the pilot program shall be carried out measuring
24health outcomes and cost of care for those served by the pilot
25program compared to similarly situated patients who are not
26served by the pilot program.

 

 

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1    The Department shall require all networks of care to
2develop a means either internally or by contract with experts
3in navigation and community outreach to navigate cancer
4patients to comprehensive care in a timely fashion. The
5Department shall require all networks of care to include access
6for patients diagnosed with cancer to at least one academic
7commission on cancer-accredited cancer program as an
8in-network covered benefit.
9    Any medical or health care provider shall immediately
10recommend, to any pregnant woman who is being provided prenatal
11services and is suspected of drug abuse or is addicted as
12defined in the Alcoholism and Other Drug Abuse and Dependency
13Act, referral to a local substance abuse treatment provider
14licensed by the Department of Human Services or to a licensed
15hospital which provides substance abuse treatment services.
16The Department of Healthcare and Family Services shall assure
17coverage for the cost of treatment of the drug abuse or
18addiction for pregnant recipients in accordance with the
19Illinois Medicaid Program in conjunction with the Department of
20Human Services.
21    All medical providers providing medical assistance to
22pregnant women under this Code shall receive information from
23the Department on the availability of services under the Drug
24Free Families with a Future or any comparable program providing
25case management services for addicted women, including
26information on appropriate referrals for other social services

 

 

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

 

 

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1in certain geographic areas. The Partnership shall be
2represented by a sponsor organization. The Department, by rule,
3shall develop qualifications for sponsors of Partnerships.
4Nothing in this Section shall be construed to require that the
5sponsor organization be a medical organization.
6    The sponsor must negotiate formal written contracts with
7medical providers for physician services, inpatient and
8outpatient hospital care, home health services, treatment for
9alcoholism and substance abuse, and other services determined
10necessary by the Illinois Department by rule for delivery by
11Partnerships. Physician services must include prenatal and
12obstetrical care. The Illinois Department shall reimburse
13medical services delivered by Partnership providers to clients
14in target areas according to provisions of this Article and the
15Illinois 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
3qualifications to participate in Partnerships to ensure the
4delivery of high quality medical services. These
5qualifications shall be determined by rule of the Illinois
6Department and may be higher than qualifications for
7participation in the medical assistance program. Partnership
8sponsors may prescribe reasonable additional qualifications
9for participation by medical providers, only with the prior
10written approval of the Illinois Department.
11    Nothing in this Section shall limit the free choice of
12practitioners, hospitals, and other providers of medical
13services by clients. In order to ensure patient freedom of
14choice, the Illinois Department shall immediately promulgate
15all rules and take all other necessary actions so that provided
16services may be accessed from therapeutically certified
17optometrists to the full extent of the Illinois Optometric
18Practice Act of 1987 without discriminating between service
19providers.
20    The Department shall apply for a waiver from the United
21States Health Care Financing Administration to allow for the
22implementation of Partnerships under this Section.
23    The Illinois Department shall require health care
24providers to maintain records that document the medical care
25and services provided to recipients of Medical Assistance under
26this Article. Such records must be retained for a period of not

 

 

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1less than 6 years from the date of service or as provided by
2applicable State law, whichever period is longer, except that
3if an audit is initiated within the required retention period
4then the records must be retained until the audit is completed
5and every exception is resolved. The Illinois Department shall
6require health care providers to make available, when
7authorized by the patient, in writing, the medical records in a
8timely fashion to other health care providers who are treating
9or serving persons eligible for Medical Assistance under this
10Article. All dispensers of medical services shall be required
11to maintain and retain business and professional records
12sufficient to fully and accurately document the nature, scope,
13details and receipt of the health care provided to persons
14eligible for medical assistance under this Code, in accordance
15with regulations promulgated by the Illinois Department. The
16rules and regulations shall require that proof of the receipt
17of prescription drugs, dentures, prosthetic devices and
18eyeglasses by eligible persons under this Section accompany
19each claim for reimbursement submitted by the dispenser of such
20medical services. No such claims for reimbursement shall be
21approved for payment by the Illinois Department without such
22proof of receipt, unless the Illinois Department shall have put
23into effect and shall be operating a system of post-payment
24audit and review which shall, on a sampling basis, be deemed
25adequate by the Illinois Department to assure that such drugs,
26dentures, prosthetic devices and eyeglasses for which payment

 

 

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1is being made are actually being received by eligible
2recipients. Within 90 days after September 16, 1984 (the
3effective date of Public Act 83-1439) this amendatory Act of
41984, the Illinois Department shall establish a current list of
5acquisition costs for all prosthetic devices and any other
6items recognized as medical equipment and supplies
7reimbursable under this Article and shall update such list on a
8quarterly basis, except that the acquisition costs of all
9prescription drugs shall be updated no less frequently than
10every 30 days as required by Section 5-5.12.
11    The rules and regulations of the Illinois Department shall
12require that a written statement including the required opinion
13of a physician shall accompany any claim for reimbursement for
14abortions, or induced miscarriages or premature births. This
15statement shall indicate what procedures were used in providing
16such medical services.
17    Notwithstanding any other law to the contrary, the Illinois
18Department shall, within 365 days after July 22, 2013 (the
19effective date of Public Act 98-104), establish procedures to
20permit skilled care facilities licensed under the Nursing Home
21Care Act to submit monthly billing claims for reimbursement
22purposes. Following development of these procedures, the
23Department shall, by July 1, 2016, test the viability of the
24new system and implement any necessary operational or
25structural changes to its information technology platforms in
26order to allow for the direct acceptance and payment of nursing

 

 

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1home claims.
2    Notwithstanding any other law to the contrary, the Illinois
3Department shall, within 365 days after August 15, 2014 (the
4effective date of Public Act 98-963), establish procedures to
5permit ID/DD facilities licensed under the ID/DD Community Care
6Act and MC/DD facilities licensed under the MC/DD Act to submit
7monthly billing claims for reimbursement purposes. Following
8development of these procedures, the Department shall have an
9additional 365 days to test the viability of the new system and
10to ensure that any necessary operational or structural changes
11to its information technology platforms are implemented.
12    The Illinois Department shall require all dispensers of
13medical services, other than an individual practitioner or
14group of practitioners, desiring to participate in the Medical
15Assistance program established under this Article to disclose
16all financial, beneficial, ownership, equity, surety or other
17interests in any and all firms, corporations, partnerships,
18associations, business enterprises, joint ventures, agencies,
19institutions or other legal entities providing any form of
20health care services in this State under this Article.
21    The Illinois Department may require that all dispensers of
22medical services desiring to participate in the medical
23assistance program established under this Article disclose,
24under such terms and conditions as the Illinois Department may
25by rule establish, all inquiries from clients and attorneys
26regarding medical bills paid by the Illinois Department, which

 

 

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1inquiries could indicate potential existence of claims or liens
2for the Illinois Department.
3    Enrollment of a vendor shall be subject to a provisional
4period and shall be conditional for one year. During the period
5of conditional enrollment, the Department may terminate the
6vendor's eligibility to participate in, or may disenroll the
7vendor from, the medical assistance program without cause.
8Unless otherwise specified, such termination of eligibility or
9disenrollment is not subject to the Department's hearing
10process. However, a disenrolled vendor may reapply without
11penalty.
12    The Department has the discretion to limit the conditional
13enrollment period for vendors based upon category of risk of
14the vendor.
15    Prior to enrollment and during the conditional enrollment
16period in the medical assistance program, all vendors shall be
17subject to enhanced oversight, screening, and review based on
18the risk of fraud, waste, and abuse that is posed by the
19category of risk of the vendor. The Illinois Department shall
20establish the procedures for oversight, screening, and review,
21which may include, but need not be limited to: criminal and
22financial background checks; fingerprinting; license,
23certification, and authorization verifications; unscheduled or
24unannounced site visits; database checks; prepayment audit
25reviews; audits; payment caps; payment suspensions; and other
26screening as required by federal or State law.

 

 

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1    The Department shall define or specify the following: (i)
2by provider notice, the "category of risk of the vendor" for
3each type of vendor, which shall take into account the level of
4screening applicable to a particular category of vendor under
5federal law and regulations; (ii) by rule or provider notice,
6the maximum length of the conditional enrollment period for
7each category of risk of the vendor; and (iii) by rule, the
8hearing rights, if any, afforded to a vendor in each category
9of risk of the vendor that is terminated or disenrolled during
10the conditional enrollment period.
11    To be eligible for payment consideration, a vendor's
12payment claim or bill, either as an initial claim or as a
13resubmitted claim following prior rejection, must be received
14by the Illinois Department, or its fiscal intermediary, no
15later than 180 days after the latest date on the claim on which
16medical goods or services were provided, with the following
17exceptions:
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
9a recipient received retroactive eligibility, claims must be
10filed within 180 days after the Department determines the
11applicant is eligible. For claims for which the Illinois
12Department is not the primary payer, claims must be submitted
13to the Illinois Department within 180 days after the final
14adjudication by the primary payer.
15    In the case of long term care facilities, within 5 days of
16receipt by the facility of required prescreening information,
17data for new admissions shall be entered into the Medical
18Electronic Data Interchange (MEDI) or the Recipient
19Eligibility Verification (REV) System or successor system, and
20within 15 days of receipt by the facility of required
21prescreening information, admission documents shall be
22submitted through MEDI or REV or shall be submitted directly to
23the Department of Human Services using required admission
24forms. Effective September 1, 2014, admission documents,
25including all prescreening information, must be submitted
26through MEDI or REV. Confirmation numbers assigned to an

 

 

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1accepted transaction shall be retained by a facility to verify
2timely submittal. Once an admission transaction has been
3completed, all resubmitted claims following prior rejection
4are subject to receipt no later than 180 days after the
5admission transaction has been completed.
6    Claims that are not submitted and received in compliance
7with the foregoing requirements shall not be eligible for
8payment under the medical assistance program, and the State
9shall have no liability for payment of those claims.
10    To the extent consistent with applicable information and
11privacy, security, and disclosure laws, State and federal
12agencies and departments shall provide the Illinois Department
13access to confidential and other information and data necessary
14to perform eligibility and payment verifications and other
15Illinois Department functions. This includes, but is not
16limited to: information pertaining to licensure;
17certification; earnings; immigration status; citizenship; wage
18reporting; unearned and earned income; pension income;
19employment; supplemental security income; social security
20numbers; National Provider Identifier (NPI) numbers; the
21National Practitioner Data Bank (NPDB); program and agency
22exclusions; taxpayer identification numbers; tax delinquency;
23corporate information; and death records.
24    The Illinois Department shall enter into agreements with
25State agencies and departments, and is authorized to enter into
26agreements with federal agencies and departments, under which

 

 

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1such agencies and departments shall share data necessary for
2medical assistance program integrity functions and oversight.
3The Illinois Department shall develop, in cooperation with
4other State departments and agencies, and in compliance with
5applicable federal laws and regulations, appropriate and
6effective methods to share such data. At a minimum, and to the
7extent necessary to provide data sharing, the Illinois
8Department shall enter into agreements with State agencies and
9departments, and is authorized to enter into agreements with
10federal agencies and departments, including but not limited to:
11the Secretary of State; the Department of Revenue; the
12Department of Public Health; the Department of Human Services;
13and the Department of Financial and Professional Regulation.
14    Beginning in fiscal year 2013, the Illinois Department
15shall set forth a request for information to identify the
16benefits of a pre-payment, post-adjudication, and post-edit
17claims system with the goals of streamlining claims processing
18and provider reimbursement, reducing the number of pending or
19rejected claims, and helping to ensure a more transparent
20adjudication process through the utilization of: (i) provider
21data verification and provider screening technology; and (ii)
22clinical code editing; and (iii) pre-pay, pre- or
23post-adjudicated predictive modeling with an integrated case
24management system with link analysis. Such a request for
25information shall not be considered as a request for proposal
26or as an obligation on the part of the Illinois Department to

 

 

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1take any action or acquire any products or services.
2    The Illinois Department shall establish policies,
3procedures, standards and criteria by rule for the acquisition,
4repair and replacement of orthotic and prosthetic devices and
5durable medical equipment. Such rules shall provide, but not be
6limited to, the following services: (1) immediate repair or
7replacement of such devices by recipients; and (2) rental,
8lease, purchase or lease-purchase of durable medical equipment
9in a cost-effective manner, taking into consideration the
10recipient's medical prognosis, the extent of the recipient's
11needs, and the requirements and costs for maintaining such
12equipment. Subject to prior approval, such rules shall enable a
13recipient to temporarily acquire and use alternative or
14substitute devices or equipment pending repairs or
15replacements of any device or equipment previously authorized
16for such recipient by the Department. Notwithstanding any
17provision of Section 5-5f to the contrary, the Department may,
18by rule, exempt certain replacement wheelchair parts from prior
19approval and, for wheelchairs, wheelchair parts, wheelchair
20accessories, and related seating and positioning items,
21determine the wholesale price by methods other than actual
22acquisition costs.
23    The Department shall require, by rule, all providers of
24durable medical equipment to be accredited by an accreditation
25organization approved by the federal Centers for Medicare and
26Medicaid Services and recognized by the Department in order to

 

 

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1bill the Department for providing durable medical equipment to
2recipients. No later than 15 months after the effective date of
3the rule adopted pursuant to this paragraph, all providers must
4meet the accreditation requirement.
5    The Department shall execute, relative to the nursing home
6prescreening project, written inter-agency agreements with the
7Department of Human Services and the Department on Aging, to
8effect the following: (i) intake procedures and common
9eligibility criteria for those persons who are receiving
10non-institutional services; and (ii) the establishment and
11development of non-institutional services in areas of the State
12where they are not currently available or are undeveloped; and
13(iii) notwithstanding any other provision of law, subject to
14federal approval, on and after July 1, 2012, an increase in the
15determination of need (DON) scores from 29 to 37 for applicants
16for institutional and home and community-based long term care;
17if and only if federal approval is not granted, the Department
18may, in conjunction with other affected agencies, implement
19utilization controls or changes in benefit packages to
20effectuate a similar savings amount for this population; and
21(iv) no later than July 1, 2013, minimum level of care
22eligibility criteria for institutional and home and
23community-based long term care; and (v) no later than October
241, 2013, establish procedures to permit long term care
25providers access to eligibility scores for individuals with an
26admission date who are seeking or receiving services from the

 

 

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1long term care provider. In order to select the minimum level
2of care eligibility criteria, the Governor shall establish a
3workgroup that includes affected agency representatives and
4stakeholders representing the institutional and home and
5community-based long term care interests. This Section shall
6not restrict the Department from implementing lower level of
7care eligibility criteria for community-based services in
8circumstances where federal approval has been granted.
9    The Illinois Department shall develop and operate, in
10cooperation with other State Departments and agencies and in
11compliance with applicable federal laws and regulations,
12appropriate and effective systems of health care evaluation and
13programs for monitoring of utilization of health care services
14and facilities, as it affects persons eligible for medical
15assistance under this Code.
16    The Illinois Department shall report annually to the
17General Assembly, no later than the second Friday in April of
181979 and each year thereafter, in regard to:
19        (a) actual statistics and trends in utilization of
20    medical services by public aid recipients;
21        (b) actual statistics and trends in the provision of
22    the various medical services by medical vendors;
23        (c) current rate structures and proposed changes in
24    those rate structures for the various medical vendors; and
25        (d) efforts at utilization review and control by the
26    Illinois Department.

 

 

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1    The period covered by each report shall be the 3 years
2ending on the June 30 prior to the report. The report shall
3include suggested legislation for consideration by the General
4Assembly. The filing of one copy of the report with the
5Speaker, one copy with the Minority Leader and one copy with
6the Clerk of the House of Representatives, one copy with the
7President, one copy with the Minority Leader and one copy with
8the Secretary of the Senate, one copy with the Legislative
9Research Unit, and such additional copies with the State
10Government Report Distribution Center for the General Assembly
11as is required under paragraph (t) of Section 7 of the State
12Library Act shall be deemed sufficient to comply with this
13Section.
14    Rulemaking authority to implement Public Act 95-1045, if
15any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate of
23reimbursement for services or other payments in accordance with
24Section 5-5e.
25    Because kidney transplantation can be an appropriate, cost
26effective alternative to renal dialysis when medically

 

 

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1necessary and notwithstanding the provisions of Section 1-11 of
2this Code, beginning October 1, 2014, the Department shall
3cover kidney transplantation for noncitizens with end-stage
4renal disease who are not eligible for comprehensive medical
5benefits, who meet the residency requirements of Section 5-3 of
6this Code, and who would otherwise meet the financial
7requirements of the appropriate class of eligible persons under
8Section 5-2 of this Code. To qualify for coverage of kidney
9transplantation, such person must be receiving emergency renal
10dialysis services covered by the Department. Providers under
11this Section shall be prior approved and certified by the
12Department to perform kidney transplantation and the services
13under this Section shall be limited to services associated with
14kidney transplantation.
15    Notwithstanding any other provision of this Code to the
16contrary, on or after July 1, 2015, all FDA approved forms of
17medication assisted treatment prescribed for the treatment of
18alcohol dependence or treatment of opioid dependence shall be
19covered under both fee for service and managed care medical
20assistance programs for persons who are otherwise eligible for
21medical assistance under this Article and shall not be subject
22to any (1) utilization control, other than those established
23under the American Society of Addiction Medicine patient
24placement criteria, (2) prior authorization mandate, or (3)
25lifetime restriction limit mandate.
26    On or after July 1, 2015, opioid antagonists prescribed for

 

 

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1the treatment of an opioid overdose, including the medication
2product, administration devices, and any pharmacy fees related
3to the dispensing and administration of the opioid antagonist,
4shall be covered under the medical assistance program for
5persons who are otherwise eligible for medical assistance under
6this Article. As used in this Section, "opioid antagonist"
7means a drug that binds to opioid receptors and blocks or
8inhibits the effect of opioids acting on those receptors,
9including, but not limited to, naloxone hydrochloride or any
10other similarly acting drug approved by the U.S. Food and Drug
11Administration.
12(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1398-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
148-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
15eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1699-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
1799 of P.A. 99-407 for its effective date); 99-433, eff.
188-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
19    Section 95. No acceleration or delay. Where this Act makes
20changes in a statute that is represented in this Act by text
21that is not yet or no longer in effect (for example, a Section
22represented by multiple versions), the use of that text does
23not accelerate or delay the taking effect of (i) the changes
24made by this Act or (ii) provisions derived from any other
25Public Act.