Full Text of SB0466 99th General Assembly
SB0466enr 99TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 356g as follows:
| 6 | | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| 7 | | (Text of Section before amendment by P.A. 99-407 ) | 8 | | Sec. 356g. Mammograms; mastectomies.
| 9 | | (a) Every insurer shall provide in each group or individual
| 10 | | policy, contract, or certificate of insurance issued or renewed | 11 | | for persons
who are residents of this State, coverage for | 12 | | screening by low-dose
mammography for all women 35 years of age | 13 | | or older for the presence of
occult breast cancer within the | 14 | | provisions of the policy, contract, or
certificate. The | 15 | | coverage shall be as follows:
| 16 | |
(1) A baseline mammogram for women 35 to 39 years of | 17 | | age.
| 18 | |
(2) An annual mammogram for women 40 years of age or | 19 | | older.
| 20 | | (3) A mammogram at the age and intervals considered | 21 | | medically necessary by the woman's health care provider for | 22 | | women under 40 years of age and having a family history of | 23 | | breast cancer, prior personal history of breast cancer, |
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| 1 | | positive genetic testing, or other risk factors.
| 2 | | (4) A comprehensive ultrasound screening of an entire | 3 | | breast or breasts if a mammogram demonstrates | 4 | | heterogeneous or dense breast tissue, when medically | 5 | | necessary as determined by a physician licensed to practice | 6 | | medicine in all of its branches. | 7 | | (5) A screening MRI when medically necessary, as | 8 | | determined by a physician licensed to practice medicine in | 9 | | all of its branches.
| 10 | | For purposes of this Section, "low-dose mammography"
means | 11 | | the x-ray examination of the breast using equipment dedicated
| 12 | | specifically for mammography, including the x-ray tube, | 13 | | filter, compression
device, and image receptor, with radiation | 14 | | exposure delivery of less than
1 rad per breast for 2 views of | 15 | | an average size breast. The term also includes digital | 16 | | mammography.
| 17 | | (a-5) Coverage as described by subsection (a) shall be | 18 | | provided at no cost to the insured and shall not be applied to | 19 | | an annual or lifetime maximum benefit. | 20 | | (a-10) When health care services are available through | 21 | | contracted providers and a person does not comply with plan | 22 | | provisions specific to the use of contracted providers, the | 23 | | requirements of subsection (a-5) are not applicable. When a | 24 | | person does not comply with plan provisions specific to the use | 25 | | of contracted providers, plan provisions specific to the use of | 26 | | non-contracted providers must be applied without distinction |
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| 1 | | for coverage required by this Section and shall be at least as | 2 | | favorable as for other radiological examinations covered by the | 3 | | policy or contract. | 4 | | (b) No policy of accident or health insurance that provides | 5 | | for
the surgical procedure known as a mastectomy shall be | 6 | | issued, amended,
delivered, or renewed in this State unless
| 7 | | that coverage also provides for prosthetic devices
or | 8 | | reconstructive surgery
incident to the mastectomy.
Coverage | 9 | | for breast reconstruction in connection with a mastectomy shall
| 10 | | include:
| 11 | | (1) reconstruction of the breast upon which the | 12 | | mastectomy has been
performed;
| 13 | | (2) surgery and reconstruction of the other breast to | 14 | | produce a
symmetrical appearance; and
| 15 | | (3) prostheses and treatment for physical | 16 | | complications at all stages of
mastectomy, including | 17 | | lymphedemas.
| 18 | | Care shall be determined in consultation with the attending | 19 | | physician and the
patient.
The offered coverage for prosthetic | 20 | | devices and
reconstructive surgery shall be subject to the | 21 | | deductible and coinsurance
conditions applied to the | 22 | | mastectomy, and all other terms and conditions
applicable to | 23 | | other benefits. When a mastectomy is performed and there is
no | 24 | | evidence of malignancy then the offered coverage may be limited | 25 | | to the
provision of prosthetic devices and reconstructive | 26 | | surgery to within 2
years after the date of the mastectomy. As |
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| 1 | | used in this Section,
"mastectomy" means the removal of all or | 2 | | part of the breast for medically
necessary reasons, as | 3 | | determined by a licensed physician.
| 4 | | Written notice of the availability of coverage under this | 5 | | Section shall be
delivered to the insured upon enrollment and | 6 | | annually thereafter. An insurer
may not deny to an insured | 7 | | eligibility, or continued eligibility, to enroll or
to renew | 8 | | coverage under the terms of the plan solely for the purpose of
| 9 | | avoiding the requirements of this Section. An insurer may not | 10 | | penalize or
reduce or
limit the reimbursement of an attending | 11 | | provider or provide incentives
(monetary or otherwise) to an | 12 | | attending provider to induce the provider to
provide care to an | 13 | | insured in a manner inconsistent with this Section.
| 14 | | (c) Rulemaking authority to implement Public Act 95-1045 | 15 | | this amendatory Act of the 95th General Assembly , if any, is | 16 | | conditioned on the rules being adopted in accordance with all | 17 | | provisions of the Illinois Administrative Procedure Act and all | 18 | | rules and procedures of the Joint Committee on Administrative | 19 | | Rules; any purported rule not so adopted, for whatever reason, | 20 | | is unauthorized. | 21 | | (Source: P.A. 99-433, eff. 8-21-15; revised 10-20-15.) | 22 | | (Text of Section after amendment by P.A. 99-407 )
| 23 | | Sec. 356g. Mammograms; mastectomies.
| 24 | | (a) Every insurer shall provide in each group or individual
| 25 | | policy, contract, or certificate of insurance issued or renewed |
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| 1 | | for persons
who are residents of this State, coverage for | 2 | | screening by low-dose
mammography for all women 35 years of age | 3 | | or older for the presence of
occult breast cancer within the | 4 | | provisions of the policy, contract, or
certificate. The | 5 | | coverage shall be as follows:
| 6 | |
(1) A baseline mammogram for women 35 to 39 years of | 7 | | age.
| 8 | |
(2) An annual mammogram for women 40 years of age or | 9 | | older.
| 10 | | (3) A mammogram at the age and intervals considered | 11 | | medically necessary by the woman's health care provider for | 12 | | women under 40 years of age and having a family history of | 13 | | breast cancer, prior personal history of breast cancer, | 14 | | positive genetic testing, or other risk factors.
| 15 | | (4) A comprehensive ultrasound screening of an entire | 16 | | breast or breasts if a mammogram demonstrates | 17 | | heterogeneous or dense breast tissue, when medically | 18 | | necessary as determined by a physician licensed to practice | 19 | | medicine in all of its branches.
| 20 | | (5) A screening MRI when medically necessary, as | 21 | | determined by a physician licensed to practice medicine in | 22 | | all of its branches.
| 23 | | For purposes of this Section, "low-dose mammography"
means | 24 | | the x-ray examination of the breast using equipment dedicated
| 25 | | specifically for mammography, including the x-ray tube, | 26 | | filter, compression
device, and image receptor, with radiation |
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| 1 | | exposure delivery of less than
1 rad per breast for 2 views of | 2 | | an average size breast. The term also includes digital | 3 | | mammography and includes breast tomosynthesis. As used in this | 4 | | Section, the term "breast tomosynthesis" means a radiologic | 5 | | procedure that involves the acquisition of projection images | 6 | | over the stationary breast to produce cross-sectional digital | 7 | | three-dimensional images of the breast.
| 8 | | If, at any time, the Secretary of the United States | 9 | | Department of Health and Human Services, or its successor | 10 | | agency, promulgates rules or regulations to be published in the | 11 | | Federal Register or publishes a comment in the Federal Register | 12 | | or issues an opinion, guidance, or other action that would | 13 | | require the State, pursuant to any provision of the Patient | 14 | | Protection and Affordable Care Act (Public Law 111-148), | 15 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 16 | | successor provision, to defray the cost of any coverage for | 17 | | breast tomosynthesis outlined in this subsection, then the | 18 | | requirement that an insurer cover breast tomosynthesis is | 19 | | inoperative other than any such coverage authorized under | 20 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 21 | | the State shall not assume any obligation for the cost of | 22 | | coverage for breast tomosynthesis set forth in this subsection. | 23 | | (a-5) Coverage as described by subsection (a) shall be | 24 | | provided at no cost to the insured and shall not be applied to | 25 | | an annual or lifetime maximum benefit. | 26 | | (a-10) When health care services are available through |
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| 1 | | contracted providers and a person does not comply with plan | 2 | | provisions specific to the use of contracted providers, the | 3 | | requirements of subsection (a-5) are not applicable. When a | 4 | | person does not comply with plan provisions specific to the use | 5 | | of contracted providers, plan provisions specific to the use of | 6 | | non-contracted providers must be applied without distinction | 7 | | for coverage required by this Section and shall be at least as | 8 | | favorable as for other radiological examinations covered by the | 9 | | policy or contract. | 10 | | (b) No policy of accident or health insurance that provides | 11 | | for
the surgical procedure known as a mastectomy shall be | 12 | | issued, amended,
delivered, or renewed in this State unless
| 13 | | that coverage also provides for prosthetic devices
or | 14 | | reconstructive surgery
incident to the mastectomy.
Coverage | 15 | | for breast reconstruction in connection with a mastectomy shall
| 16 | | include:
| 17 | | (1) reconstruction of the breast upon which the | 18 | | mastectomy has been
performed;
| 19 | | (2) surgery and reconstruction of the other breast to | 20 | | produce a
symmetrical appearance; and
| 21 | | (3) prostheses and treatment for physical | 22 | | complications at all stages of
mastectomy, including | 23 | | lymphedemas.
| 24 | | Care shall be determined in consultation with the attending | 25 | | physician and the
patient.
The offered coverage for prosthetic | 26 | | devices and
reconstructive surgery shall be subject to the |
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| 1 | | deductible and coinsurance
conditions applied to the | 2 | | mastectomy, and all other terms and conditions
applicable to | 3 | | other benefits. When a mastectomy is performed and there is
no | 4 | | evidence of malignancy then the offered coverage may be limited | 5 | | to the
provision of prosthetic devices and reconstructive | 6 | | surgery to within 2
years after the date of the mastectomy. As | 7 | | used in this Section,
"mastectomy" means the removal of all or | 8 | | part of the breast for medically
necessary reasons, as | 9 | | determined by a licensed physician.
| 10 | | Written notice of the availability of coverage under this | 11 | | Section shall be
delivered to the insured upon enrollment and | 12 | | annually thereafter. An insurer
may not deny to an insured | 13 | | eligibility, or continued eligibility, to enroll or
to renew | 14 | | coverage under the terms of the plan solely for the purpose of
| 15 | | avoiding the requirements of this Section. An insurer may not | 16 | | penalize or
reduce or
limit the reimbursement of an attending | 17 | | provider or provide incentives
(monetary or otherwise) to an | 18 | | attending provider to induce the provider to
provide care to an | 19 | | insured in a manner inconsistent with this Section.
| 20 | | (c) Rulemaking authority to implement Public Act 95-1045 | 21 | | this amendatory Act of the 95th General Assembly , if any, is | 22 | | conditioned on the rules being adopted in accordance with all | 23 | | provisions of the Illinois Administrative Procedure Act and all | 24 | | rules and procedures of the Joint Committee on Administrative | 25 | | Rules; any purported rule not so adopted, for whatever reason, | 26 | | is unauthorized. |
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| 1 | | (Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its | 2 | | effective date); 99-433, eff. 8-21-15; revised 10-20-15.) | 3 | | Section 10. The Health Maintenance Organization Act is | 4 | | amended by changing Section 4-6.1 as follows:
| 5 | | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| 6 | | (Text of Section before amendment by P.A. 99-407 )
| 7 | | Sec. 4-6.1. Mammograms; mastectomies.
| 8 | | (a) Every contract or evidence of coverage
issued by a | 9 | | Health Maintenance Organization for persons who are residents | 10 | | of
this State shall contain coverage for screening by low-dose | 11 | | mammography
for all women 35 years of age or older for the | 12 | | presence of occult breast
cancer. The coverage shall be as | 13 | | follows:
| 14 | | (1) A baseline mammogram for women 35 to 39 years of | 15 | | age.
| 16 | | (2) An annual mammogram for women 40 years of age or | 17 | | older.
| 18 | | (3) A mammogram at the age and intervals considered | 19 | | medically necessary by the woman's health care provider for | 20 | | women under 40 years of age and having a family history of | 21 | | breast cancer, prior personal history of breast cancer, | 22 | | positive genetic testing, or other risk factors. | 23 | | (4) A comprehensive ultrasound screening of an entire | 24 | | breast or breasts if a mammogram demonstrates |
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| 1 | | heterogeneous or dense breast tissue, when medically | 2 | | necessary as determined by a physician licensed to practice | 3 | | medicine in all of its branches.
| 4 | | For purposes of this Section, "low-dose mammography"
means | 5 | | the x-ray examination of the breast using equipment dedicated
| 6 | | specifically for mammography, including the x-ray tube, | 7 | | filter, compression
device, and image receptor, with radiation | 8 | | exposure delivery of less than 1
rad per breast for 2 views of | 9 | | an average size breast. The term also includes digital | 10 | | mammography.
| 11 | | (a-5) Coverage as described in subsection (a) shall be | 12 | | provided at no cost to the enrollee and shall not be applied to | 13 | | an annual or lifetime maximum benefit. | 14 | | (b) No contract or evidence of coverage issued by a health | 15 | | maintenance
organization that provides for the
surgical | 16 | | procedure known as a mastectomy shall be issued, amended, | 17 | | delivered,
or renewed in this State on or after the effective | 18 | | date of this amendatory Act
of the 92nd General Assembly unless | 19 | | that coverage also provides for prosthetic
devices or | 20 | | reconstructive surgery incident to the mastectomy, providing | 21 | | that
the mastectomy is performed after the effective date of | 22 | | this amendatory Act.
Coverage for breast reconstruction in | 23 | | connection
with a mastectomy shall
include:
| 24 | | (1) reconstruction of the breast upon which the | 25 | | mastectomy has been
performed;
| 26 | | (2) surgery and reconstruction of the other breast to |
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| 1 | | produce a
symmetrical appearance; and
| 2 | | (3) prostheses and treatment for physical | 3 | | complications at all stages of
mastectomy, including | 4 | | lymphedemas.
| 5 | | Care shall be determined in consultation with the attending | 6 | | physician and the
patient.
The offered coverage for prosthetic | 7 | | devices and
reconstructive surgery shall be subject to the | 8 | | deductible and coinsurance
conditions applied to the | 9 | | mastectomy and all other terms and conditions
applicable to | 10 | | other benefits. When a mastectomy is performed and there is
no | 11 | | evidence of malignancy, then the offered coverage may be | 12 | | limited to the
provision of prosthetic devices and | 13 | | reconstructive surgery to within 2
years after the date of the | 14 | | mastectomy. As used in this Section,
"mastectomy" means the | 15 | | removal of all or part of the breast for medically
necessary | 16 | | reasons, as determined by a licensed physician.
| 17 | | Written notice of the availability of coverage under this | 18 | | Section shall be
delivered to the enrollee upon enrollment and | 19 | | annually thereafter. A
health maintenance organization may not | 20 | | deny to an enrollee eligibility, or
continued eligibility, to | 21 | | enroll or
to renew coverage under the terms of the plan solely | 22 | | for the purpose of
avoiding the requirements of this Section. A | 23 | | health maintenance organization
may not penalize or
reduce or
| 24 | | limit the reimbursement of an attending provider or provide | 25 | | incentives
(monetary or otherwise) to an attending provider to | 26 | | induce the provider to
provide care to an insured in a manner |
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| 1 | | inconsistent with this Section.
| 2 | | (c) Rulemaking authority to implement this amendatory Act | 3 | | of the 95th General Assembly, if any, is conditioned on the | 4 | | rules being adopted in accordance with all provisions of the | 5 | | Illinois Administrative Procedure Act and all rules and | 6 | | procedures of the Joint Committee on Administrative Rules; any | 7 | | purported rule not so adopted, for whatever reason, is | 8 | | unauthorized. | 9 | | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 10 | | 95-1045, eff. 3-27-09.)
| 11 | | (Text of Section after amendment by P.A. 99-407 )
| 12 | | Sec. 4-6.1. Mammograms; mastectomies.
| 13 | | (a) Every contract or evidence of coverage
issued by a | 14 | | Health Maintenance Organization for persons who are residents | 15 | | of
this State shall contain coverage for screening by low-dose | 16 | | mammography
for all women 35 years of age or older for the | 17 | | presence of occult breast
cancer. The coverage shall be as | 18 | | follows:
| 19 | | (1) A baseline mammogram for women 35 to 39 years of | 20 | | age.
| 21 | | (2) An annual mammogram for women 40 years of age or | 22 | | older.
| 23 | | (3) A mammogram at the age and intervals considered | 24 | | medically necessary by the woman's health care provider for | 25 | | women under 40 years of age and having a family history of |
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| 1 | | breast cancer, prior personal history of breast cancer, | 2 | | positive genetic testing, or other risk factors. | 3 | | (4) A comprehensive ultrasound screening of an entire | 4 | | breast or breasts if a mammogram demonstrates | 5 | | heterogeneous or dense breast tissue, when medically | 6 | | necessary as determined by a physician licensed to practice | 7 | | medicine in all of its branches.
| 8 | | For purposes of this Section, "low-dose mammography"
means | 9 | | the x-ray examination of the breast using equipment dedicated
| 10 | | specifically for mammography, including the x-ray tube, | 11 | | filter, compression
device, and image receptor, with radiation | 12 | | exposure delivery of less than 1
rad per breast for 2 views of | 13 | | an average size breast. The term also includes digital | 14 | | mammography and includes breast tomosynthesis. As used in this | 15 | | Section, the term "breast tomosynthesis" means a radiologic | 16 | | procedure that involves the acquisition of projection images | 17 | | over the stationary breast to produce cross-sectional digital | 18 | | three-dimensional images of the breast.
| 19 | | If, at any time, the Secretary of the United States | 20 | | Department of Health and Human Services, or its successor | 21 | | agency, promulgates rules or regulations to be published in the | 22 | | Federal Register or publishes a comment in the Federal Register | 23 | | or issues an opinion, guidance, or other action that would | 24 | | require the State, pursuant to any provision of the Patient | 25 | | Protection and Affordable Care Act (Public Law 111-148), | 26 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any |
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| 1 | | successor provision, to defray the cost of any coverage for | 2 | | breast tomosynthesis outlined in this subsection, then the | 3 | | requirement that an insurer cover breast tomosynthesis is | 4 | | inoperative other than any such coverage authorized under | 5 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 6 | | the State shall not assume any obligation for the cost of | 7 | | coverage for breast tomosynthesis set forth in this subsection. | 8 | | (a-5) Coverage as described in subsection (a) shall be | 9 | | provided at no cost to the enrollee and shall not be applied to | 10 | | an annual or lifetime maximum benefit. | 11 | | (b) No contract or evidence of coverage issued by a health | 12 | | maintenance
organization that provides for the
surgical | 13 | | procedure known as a mastectomy shall be issued, amended, | 14 | | delivered,
or renewed in this State on or after the effective | 15 | | date of this amendatory Act
of the 92nd General Assembly unless | 16 | | that coverage also provides for prosthetic
devices or | 17 | | reconstructive surgery incident to the mastectomy, providing | 18 | | that
the mastectomy is performed after the effective date of | 19 | | this amendatory Act.
Coverage for breast reconstruction in | 20 | | connection
with a mastectomy shall
include:
| 21 | | (1) reconstruction of the breast upon which the | 22 | | mastectomy has been
performed;
| 23 | | (2) surgery and reconstruction of the other breast to | 24 | | produce a
symmetrical appearance; and
| 25 | | (3) prostheses and treatment for physical | 26 | | complications at all stages of
mastectomy, including |
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| 1 | | lymphedemas.
| 2 | | Care shall be determined in consultation with the attending | 3 | | physician and the
patient.
The offered coverage for prosthetic | 4 | | devices and
reconstructive surgery shall be subject to the | 5 | | deductible and coinsurance
conditions applied to the | 6 | | mastectomy and all other terms and conditions
applicable to | 7 | | other benefits. When a mastectomy is performed and there is
no | 8 | | evidence of malignancy, then the offered coverage may be | 9 | | limited to the
provision of prosthetic devices and | 10 | | reconstructive surgery to within 2
years after the date of the | 11 | | mastectomy. As used in this Section,
"mastectomy" means the | 12 | | removal of all or part of the breast for medically
necessary | 13 | | reasons, as determined by a licensed physician.
| 14 | | Written notice of the availability of coverage under this | 15 | | Section shall be
delivered to the enrollee upon enrollment and | 16 | | annually thereafter. A
health maintenance organization may not | 17 | | deny to an enrollee eligibility, or
continued eligibility, to | 18 | | enroll or
to renew coverage under the terms of the plan solely | 19 | | for the purpose of
avoiding the requirements of this Section. A | 20 | | health maintenance organization
may not penalize or
reduce or
| 21 | | limit the reimbursement of an attending provider or provide | 22 | | incentives
(monetary or otherwise) to an attending provider to | 23 | | induce the provider to
provide care to an insured in a manner | 24 | | inconsistent with this Section.
| 25 | | (c) Rulemaking authority to implement this amendatory Act | 26 | | of the 95th General Assembly, if any, is conditioned on the |
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| 1 | | rules being adopted in accordance with all provisions of the | 2 | | Illinois Administrative Procedure Act and all rules and | 3 | | procedures of the Joint Committee on Administrative Rules; any | 4 | | purported rule not so adopted, for whatever reason, is | 5 | | unauthorized. | 6 | | (Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its | 7 | | effective date).)
| 8 | | Section 15. The Illinois Public Aid Code is amended by | 9 | | changing Section 5-5 as follows:
| 10 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 11 | | (Text of Section before amendment by P.A. 99-407 ) | 12 | | Sec. 5-5. Medical services. The Illinois Department, by | 13 | | rule, shall
determine the quantity and quality of and the rate | 14 | | of reimbursement for the
medical assistance for which
payment | 15 | | will be authorized, and the medical services to be provided,
| 16 | | which may include all or part of the following: (1) inpatient | 17 | | hospital
services; (2) outpatient hospital services; (3) other | 18 | | laboratory and
X-ray services; (4) skilled nursing home | 19 | | services; (5) physicians'
services whether furnished in the | 20 | | office, the patient's home, a
hospital, a skilled nursing home, | 21 | | or elsewhere; (6) medical care, or any
other type of remedial | 22 | | care furnished by licensed practitioners; (7)
home health care | 23 | | services; (8) private duty nursing service; (9) clinic
| 24 | | services; (10) dental services, including prevention and |
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| 1 | | treatment of periodontal disease and dental caries disease for | 2 | | pregnant women, provided by an individual licensed to practice | 3 | | dentistry or dental surgery; for purposes of this item (10), | 4 | | "dental services" means diagnostic, preventive, or corrective | 5 | | procedures provided by or under the supervision of a dentist in | 6 | | the practice of his or her profession; (11) physical therapy | 7 | | and related
services; (12) prescribed drugs, dentures, and | 8 | | prosthetic devices; and
eyeglasses prescribed by a physician | 9 | | skilled in the diseases of the eye,
or by an optometrist, | 10 | | whichever the person may select; (13) other
diagnostic, | 11 | | screening, preventive, and rehabilitative services, including | 12 | | to ensure that the individual's need for intervention or | 13 | | treatment of mental disorders or substance use disorders or | 14 | | co-occurring mental health and substance use disorders is | 15 | | determined using a uniform screening, assessment, and | 16 | | evaluation process inclusive of criteria, for children and | 17 | | adults; for purposes of this item (13), a uniform screening, | 18 | | assessment, and evaluation process refers to a process that | 19 | | includes an appropriate evaluation and, as warranted, a | 20 | | referral; "uniform" does not mean the use of a singular | 21 | | instrument, tool, or process that all must utilize; (14)
| 22 | | transportation and such other expenses as may be necessary; | 23 | | (15) medical
treatment of sexual assault survivors, as defined | 24 | | in
Section 1a of the Sexual Assault Survivors Emergency | 25 | | Treatment Act, for
injuries sustained as a result of the sexual | 26 | | assault, including
examinations and laboratory tests to |
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| 1 | | discover evidence which may be used in
criminal proceedings | 2 | | arising from the sexual assault; (16) the
diagnosis and | 3 | | treatment of sickle cell anemia; and (17)
any other medical | 4 | | care, and any other type of remedial care recognized
under the | 5 | | laws of this State, but not including abortions, or induced
| 6 | | miscarriages or premature births, unless, in the opinion of a | 7 | | physician,
such procedures are necessary for the preservation | 8 | | of the life of the
woman seeking such treatment, or except an | 9 | | induced premature birth
intended to produce a live viable child | 10 | | and such procedure is necessary
for the health of the mother or | 11 | | her unborn child. The Illinois Department,
by rule, shall | 12 | | prohibit any physician from providing medical assistance
to | 13 | | anyone eligible therefor under this Code where such physician | 14 | | has been
found guilty of performing an abortion procedure in a | 15 | | wilful and wanton
manner upon a woman who was not pregnant at | 16 | | the time such abortion
procedure was performed. The term "any | 17 | | other type of remedial care" shall
include nursing care and | 18 | | nursing home service for persons who rely on
treatment by | 19 | | spiritual means alone through prayer for healing.
| 20 | | Notwithstanding any other provision of this Section, a | 21 | | comprehensive
tobacco use cessation program that includes | 22 | | purchasing prescription drugs or
prescription medical devices | 23 | | approved by the Food and Drug Administration shall
be covered | 24 | | under the medical assistance
program under this Article for | 25 | | persons who are otherwise eligible for
assistance under this | 26 | | Article.
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| 1 | | Notwithstanding any other provision of this Code, the | 2 | | Illinois
Department may not require, as a condition of payment | 3 | | for any laboratory
test authorized under this Article, that a | 4 | | physician's handwritten signature
appear on the laboratory | 5 | | test order form. The Illinois Department may,
however, impose | 6 | | other appropriate requirements regarding laboratory test
order | 7 | | documentation.
| 8 | | Upon receipt of federal approval of an amendment to the | 9 | | Illinois Title XIX State Plan for this purpose, the Department | 10 | | shall authorize the Chicago Public Schools (CPS) to procure a | 11 | | vendor or vendors to manufacture eyeglasses for individuals | 12 | | enrolled in a school within the CPS system. CPS shall ensure | 13 | | that its vendor or vendors are enrolled as providers in the | 14 | | medical assistance program and in any capitated Medicaid | 15 | | managed care entity (MCE) serving individuals enrolled in a | 16 | | school within the CPS system. Under any contract procured under | 17 | | this provision, the vendor or vendors must serve only | 18 | | individuals enrolled in a school within the CPS system. Claims | 19 | | for services provided by CPS's vendor or vendors to recipients | 20 | | of benefits in the medical assistance program under this Code, | 21 | | the Children's Health Insurance Program, or the Covering ALL | 22 | | KIDS Health Insurance Program shall be submitted to the | 23 | | Department or the MCE in which the individual is enrolled for | 24 | | payment and shall be reimbursed at the Department's or the | 25 | | MCE's established rates or rate methodologies for eyeglasses. | 26 | | On and after July 1, 2012, the Department of Healthcare and |
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| 1 | | Family Services may provide the following services to
persons
| 2 | | eligible for assistance under this Article who are | 3 | | participating in
education, training or employment programs | 4 | | operated by the Department of Human
Services as successor to | 5 | | the Department of Public Aid:
| 6 | | (1) dental services provided by or under the | 7 | | supervision of a dentist; and
| 8 | | (2) eyeglasses prescribed by a physician skilled in the | 9 | | diseases of the
eye, or by an optometrist, whichever the | 10 | | person may select.
| 11 | | Notwithstanding any other provision of this Code and | 12 | | subject to federal approval, the Department may adopt rules to | 13 | | allow a dentist who is volunteering his or her service at no | 14 | | cost to render dental services through an enrolled | 15 | | not-for-profit health clinic without the dentist personally | 16 | | enrolling as a participating provider in the medical assistance | 17 | | program. A not-for-profit health clinic shall include a public | 18 | | health clinic or Federally Qualified Health Center or other | 19 | | enrolled provider, as determined by the Department, through | 20 | | which dental services covered under this Section are performed. | 21 | | The Department shall establish a process for payment of claims | 22 | | for reimbursement for covered dental services rendered under | 23 | | this provision. | 24 | | The Illinois Department, by rule, may distinguish and | 25 | | classify the
medical services to be provided only in accordance | 26 | | with the classes of
persons designated in Section 5-2.
|
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| 1 | | The Department of Healthcare and Family Services must | 2 | | provide coverage and reimbursement for amino acid-based | 3 | | elemental formulas, regardless of delivery method, for the | 4 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 5 | | short bowel syndrome when the prescribing physician has issued | 6 | | a written order stating that the amino acid-based elemental | 7 | | formula is medically necessary.
| 8 | | The Illinois Department shall authorize the provision of, | 9 | | and shall
authorize payment for, screening by low-dose | 10 | | mammography for the presence of
occult breast cancer for women | 11 | | 35 years of age or older who are eligible
for medical | 12 | | assistance under this Article, as follows: | 13 | | (A) A baseline
mammogram for women 35 to 39 years of | 14 | | age.
| 15 | | (B) An annual mammogram for women 40 years of age or | 16 | | older. | 17 | | (C) A mammogram at the age and intervals considered | 18 | | medically necessary by the woman's health care provider for | 19 | | women under 40 years of age and having a family history of | 20 | | breast cancer, prior personal history of breast cancer, | 21 | | positive genetic testing, or other risk factors. | 22 | | (D) A comprehensive ultrasound screening of an entire | 23 | | breast or breasts if a mammogram demonstrates | 24 | | heterogeneous or dense breast tissue, when medically | 25 | | necessary as determined by a physician licensed to practice | 26 | | medicine in all of its branches. |
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| 1 | | (E) A screening MRI when medically necessary, as | 2 | | determined by a physician licensed to practice medicine in | 3 | | all of its branches. | 4 | | All screenings
shall
include a physical breast exam, | 5 | | instruction on self-examination and
information regarding the | 6 | | frequency of self-examination and its value as a
preventative | 7 | | tool. For purposes of this Section, "low-dose mammography" | 8 | | means
the x-ray examination of the breast using equipment | 9 | | dedicated specifically
for mammography, including the x-ray | 10 | | tube, filter, compression device,
and image receptor, with an | 11 | | average radiation exposure delivery
of less than one rad per | 12 | | breast for 2 views of an average size breast.
The term also | 13 | | includes digital mammography.
| 14 | | On and after January 1, 2016, the Department shall ensure | 15 | | that all networks of care for adult clients of the Department | 16 | | include access to at least one breast imaging Center of Imaging | 17 | | Excellence as certified by the American College of Radiology. | 18 | | On and after January 1, 2012, providers participating in a | 19 | | quality improvement program approved by the Department shall be | 20 | | reimbursed for screening and diagnostic mammography at the same | 21 | | rate as the Medicare program's rates, including the increased | 22 | | reimbursement for digital mammography. | 23 | | The Department shall convene an expert panel including | 24 | | representatives of hospitals, free-standing mammography | 25 | | facilities, and doctors, including radiologists, to establish | 26 | | quality standards for mammography. |
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| 1 | | On and after January 1, 2017, providers participating in a | 2 | | breast cancer treatment quality improvement program approved | 3 | | by the Department shall be reimbursed for breast cancer | 4 | | treatment at a rate that is no lower than 95% of the Medicare | 5 | | program's rates for the data elements included in the breast | 6 | | cancer treatment quality program. | 7 | | The Department shall convene an expert panel, including | 8 | | representatives of hospitals, free standing breast cancer | 9 | | treatment centers, breast cancer quality organizations, and | 10 | | doctors, including breast surgeons, reconstructive breast | 11 | | surgeons, oncologists, and primary care providers to establish | 12 | | quality standards for breast cancer treatment. | 13 | | Subject to federal approval, the Department shall | 14 | | establish a rate methodology for mammography at federally | 15 | | qualified health centers and other encounter-rate clinics. | 16 | | These clinics or centers may also collaborate with other | 17 | | hospital-based mammography facilities. By January 1, 2016, the | 18 | | Department shall report to the General Assembly on the status | 19 | | of the provision set forth in this paragraph. | 20 | | The Department shall establish a methodology to remind | 21 | | women who are age-appropriate for screening mammography, but | 22 | | who have not received a mammogram within the previous 18 | 23 | | months, of the importance and benefit of screening mammography. | 24 | | The Department shall work with experts in breast cancer | 25 | | outreach and patient navigation to optimize these reminders and | 26 | | shall establish a methodology for evaluating their |
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| 1 | | effectiveness and modifying the methodology based on the | 2 | | evaluation. | 3 | | The Department shall establish a performance goal for | 4 | | primary care providers with respect to their female patients | 5 | | over age 40 receiving an annual mammogram. This performance | 6 | | goal shall be used to provide additional reimbursement in the | 7 | | form of a quality performance bonus to primary care providers | 8 | | who meet that goal. | 9 | | The Department shall devise a means of case-managing or | 10 | | patient navigation for beneficiaries diagnosed with breast | 11 | | cancer. This program shall initially operate as a pilot program | 12 | | in areas of the State with the highest incidence of mortality | 13 | | related to breast cancer. At least one pilot program site shall | 14 | | be in the metropolitan Chicago area and at least one site shall | 15 | | be outside the metropolitan Chicago area. On or after July 1, | 16 | | 2016, the pilot program shall be expanded to include one site | 17 | | in western Illinois, one site in southern Illinois, one site in | 18 | | central Illinois, and 4 sites within metropolitan Chicago. An | 19 | | evaluation of the pilot program shall be carried out measuring | 20 | | health outcomes and cost of care for those served by the pilot | 21 | | program compared to similarly situated patients who are not | 22 | | served by the pilot program. | 23 | | The Department shall require all networks of care to | 24 | | develop a means either internally or by contract with experts | 25 | | in navigation and community outreach to navigate cancer | 26 | | patients to comprehensive care in a timely fashion. The |
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| 1 | | Department shall require all networks of care to include access | 2 | | for patients diagnosed with cancer to at least one academic | 3 | | commission on cancer-accredited cancer program as an | 4 | | in-network covered benefit. | 5 | | Any medical or health care provider shall immediately | 6 | | recommend, to
any pregnant woman who is being provided prenatal | 7 | | services and is suspected
of drug abuse or is addicted as | 8 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 9 | | Act, referral to a local substance abuse treatment provider
| 10 | | licensed by the Department of Human Services or to a licensed
| 11 | | hospital which provides substance abuse treatment services. | 12 | | The Department of Healthcare and Family Services
shall assure | 13 | | coverage for the cost of treatment of the drug abuse or
| 14 | | addiction for pregnant recipients in accordance with the | 15 | | Illinois Medicaid
Program in conjunction with the Department of | 16 | | Human Services.
| 17 | | All medical providers providing medical assistance to | 18 | | pregnant women
under this Code shall receive information from | 19 | | the Department on the
availability of services under the Drug | 20 | | Free Families with a Future or any
comparable program providing | 21 | | case management services for addicted women,
including | 22 | | information on appropriate referrals for other social services
| 23 | | that may be needed by addicted women in addition to treatment | 24 | | for addiction.
| 25 | | The Illinois Department, in cooperation with the | 26 | | Departments of Human
Services (as successor to the Department |
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| 1 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 2 | | public awareness campaign, may
provide information concerning | 3 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 4 | | health care, and other pertinent programs directed at
reducing | 5 | | the number of drug-affected infants born to recipients of | 6 | | medical
assistance.
| 7 | | Neither the Department of Healthcare and Family Services | 8 | | nor the Department of Human
Services shall sanction the | 9 | | recipient solely on the basis of
her substance abuse.
| 10 | | The Illinois Department shall establish such regulations | 11 | | governing
the dispensing of health services under this Article | 12 | | as it shall deem
appropriate. The Department
should
seek the | 13 | | advice of formal professional advisory committees appointed by
| 14 | | the Director of the Illinois Department for the purpose of | 15 | | providing regular
advice on policy and administrative matters, | 16 | | information dissemination and
educational activities for | 17 | | medical and health care providers, and
consistency in | 18 | | procedures to the Illinois Department.
| 19 | | The Illinois Department may develop and contract with | 20 | | Partnerships of
medical providers to arrange medical services | 21 | | for persons eligible under
Section 5-2 of this Code. | 22 | | Implementation of this Section may be by
demonstration projects | 23 | | in certain geographic areas. The Partnership shall
be | 24 | | represented by a sponsor organization. The Department, by rule, | 25 | | shall
develop qualifications for sponsors of Partnerships. | 26 | | Nothing in this
Section shall be construed to require that the |
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| 1 | | sponsor organization be a
medical organization.
| 2 | | The sponsor must negotiate formal written contracts with | 3 | | medical
providers for physician services, inpatient and | 4 | | outpatient hospital care,
home health services, treatment for | 5 | | alcoholism and substance abuse, and
other services determined | 6 | | necessary by the Illinois Department by rule for
delivery by | 7 | | Partnerships. Physician services must include prenatal and
| 8 | | obstetrical care. The Illinois Department shall reimburse | 9 | | medical services
delivered by Partnership providers to clients | 10 | | in target areas according to
provisions of this Article and the | 11 | | Illinois Health Finance Reform Act,
except that:
| 12 | | (1) Physicians participating in a Partnership and | 13 | | providing certain
services, which shall be determined by | 14 | | the Illinois Department, to persons
in areas covered by the | 15 | | Partnership may receive an additional surcharge
for such | 16 | | services.
| 17 | | (2) The Department may elect to consider and negotiate | 18 | | financial
incentives to encourage the development of | 19 | | Partnerships and the efficient
delivery of medical care.
| 20 | | (3) Persons receiving medical services through | 21 | | Partnerships may receive
medical and case management | 22 | | services above the level usually offered
through the | 23 | | medical assistance program.
| 24 | | Medical providers shall be required to meet certain | 25 | | qualifications to
participate in Partnerships to ensure the | 26 | | delivery of high quality medical
services. These |
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| 1 | | qualifications shall be determined by rule of the Illinois
| 2 | | Department and may be higher than qualifications for | 3 | | participation in the
medical assistance program. Partnership | 4 | | sponsors may prescribe reasonable
additional qualifications | 5 | | for participation by medical providers, only with
the prior | 6 | | written approval of the Illinois Department.
| 7 | | Nothing in this Section shall limit the free choice of | 8 | | practitioners,
hospitals, and other providers of medical | 9 | | services by clients.
In order to ensure patient freedom of | 10 | | choice, the Illinois Department shall
immediately promulgate | 11 | | all rules and take all other necessary actions so that
provided | 12 | | services may be accessed from therapeutically certified | 13 | | optometrists
to the full extent of the Illinois Optometric | 14 | | Practice Act of 1987 without
discriminating between service | 15 | | providers.
| 16 | | The Department shall apply for a waiver from the United | 17 | | States Health
Care Financing Administration to allow for the | 18 | | implementation of
Partnerships under this Section.
| 19 | | The Illinois Department shall require health care | 20 | | providers to maintain
records that document the medical care | 21 | | and services provided to recipients
of Medical Assistance under | 22 | | this Article. Such records must be retained for a period of not | 23 | | less than 6 years from the date of service or as provided by | 24 | | applicable State law, whichever period is longer, except that | 25 | | if an audit is initiated within the required retention period | 26 | | then the records must be retained until the audit is completed |
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| 1 | | and every exception is resolved. The Illinois Department shall
| 2 | | require health care providers to make available, when | 3 | | authorized by the
patient, in writing, the medical records in a | 4 | | timely fashion to other
health care providers who are treating | 5 | | or serving persons eligible for
Medical Assistance under this | 6 | | Article. All dispensers of medical services
shall be required | 7 | | to maintain and retain business and professional records
| 8 | | sufficient to fully and accurately document the nature, scope, | 9 | | details and
receipt of the health care provided to persons | 10 | | eligible for medical
assistance under this Code, in accordance | 11 | | with regulations promulgated by
the Illinois Department. The | 12 | | rules and regulations shall require that proof
of the receipt | 13 | | of prescription drugs, dentures, prosthetic devices and
| 14 | | eyeglasses by eligible persons under this Section accompany | 15 | | each claim
for reimbursement submitted by the dispenser of such | 16 | | medical services.
No such claims for reimbursement shall be | 17 | | approved for payment by the Illinois
Department without such | 18 | | proof of receipt, unless the Illinois Department
shall have put | 19 | | into effect and shall be operating a system of post-payment
| 20 | | audit and review which shall, on a sampling basis, be deemed | 21 | | adequate by
the Illinois Department to assure that such drugs, | 22 | | dentures, prosthetic
devices and eyeglasses for which payment | 23 | | is being made are actually being
received by eligible | 24 | | recipients. Within 90 days after September 16, 1984 ( the | 25 | | effective date of Public Act 83-1439)
this amendatory Act of | 26 | | 1984 , the Illinois Department shall establish a
current list of |
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| 1 | | acquisition costs for all prosthetic devices and any
other | 2 | | items recognized as medical equipment and supplies | 3 | | reimbursable under
this Article and shall update such list on a | 4 | | quarterly basis, except that
the acquisition costs of all | 5 | | prescription drugs shall be updated no
less frequently than | 6 | | every 30 days as required by Section 5-5.12.
| 7 | | The rules and regulations of the Illinois Department shall | 8 | | require
that a written statement including the required opinion | 9 | | of a physician
shall accompany any claim for reimbursement for | 10 | | abortions, or induced
miscarriages or premature births. This | 11 | | statement shall indicate what
procedures were used in providing | 12 | | such medical services.
| 13 | | Notwithstanding any other law to the contrary, the Illinois | 14 | | Department shall, within 365 days after July 22, 2013 (the | 15 | | effective date of Public Act 98-104), establish procedures to | 16 | | permit skilled care facilities licensed under the Nursing Home | 17 | | Care Act to submit monthly billing claims for reimbursement | 18 | | purposes. Following development of these procedures, the | 19 | | Department shall, by July 1, 2016, test the viability of the | 20 | | new system and implement any necessary operational or | 21 | | structural changes to its information technology platforms in | 22 | | order to allow for the direct acceptance and payment of nursing | 23 | | home claims. | 24 | | Notwithstanding any other law to the contrary, the Illinois | 25 | | Department shall, within 365 days after August 15, 2014 (the | 26 | | effective date of Public Act 98-963), establish procedures to |
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| 1 | | permit ID/DD facilities licensed under the ID/DD Community Care | 2 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 3 | | monthly billing claims for reimbursement purposes. Following | 4 | | development of these procedures, the Department shall have an | 5 | | additional 365 days to test the viability of the new system and | 6 | | to ensure that any necessary operational or structural changes | 7 | | to its information technology platforms are implemented. | 8 | | The Illinois Department shall require all dispensers of | 9 | | medical
services, other than an individual practitioner or | 10 | | group of practitioners,
desiring to participate in the Medical | 11 | | Assistance program
established under this Article to disclose | 12 | | all financial, beneficial,
ownership, equity, surety or other | 13 | | interests in any and all firms,
corporations, partnerships, | 14 | | associations, business enterprises, joint
ventures, agencies, | 15 | | institutions or other legal entities providing any
form of | 16 | | health care services in this State under this Article.
| 17 | | The Illinois Department may require that all dispensers of | 18 | | medical
services desiring to participate in the medical | 19 | | assistance program
established under this Article disclose, | 20 | | under such terms and conditions as
the Illinois Department may | 21 | | by rule establish, all inquiries from clients
and attorneys | 22 | | regarding medical bills paid by the Illinois Department, which
| 23 | | inquiries could indicate potential existence of claims or liens | 24 | | for the
Illinois Department.
| 25 | | Enrollment of a vendor
shall be
subject to a provisional | 26 | | period and shall be conditional for one year. During the period |
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| 1 | | of conditional enrollment, the Department may
terminate the | 2 | | vendor's eligibility to participate in, or may disenroll the | 3 | | vendor from, the medical assistance
program without cause. | 4 | | Unless otherwise specified, such termination of eligibility or | 5 | | disenrollment is not subject to the
Department's hearing | 6 | | process.
However, a disenrolled vendor may reapply without | 7 | | penalty.
| 8 | | The Department has the discretion to limit the conditional | 9 | | enrollment period for vendors based upon category of risk of | 10 | | the vendor. | 11 | | Prior to enrollment and during the conditional enrollment | 12 | | period in the medical assistance program, all vendors shall be | 13 | | subject to enhanced oversight, screening, and review based on | 14 | | the risk of fraud, waste, and abuse that is posed by the | 15 | | category of risk of the vendor. The Illinois Department shall | 16 | | establish the procedures for oversight, screening, and review, | 17 | | which may include, but need not be limited to: criminal and | 18 | | financial background checks; fingerprinting; license, | 19 | | certification, and authorization verifications; unscheduled or | 20 | | unannounced site visits; database checks; prepayment audit | 21 | | reviews; audits; payment caps; payment suspensions; and other | 22 | | screening as required by federal or State law. | 23 | | The Department shall define or specify the following: (i) | 24 | | by provider notice, the "category of risk of the vendor" for | 25 | | each type of vendor, which shall take into account the level of | 26 | | screening applicable to a particular category of vendor under |
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| 1 | | federal law and regulations; (ii) by rule or provider notice, | 2 | | the maximum length of the conditional enrollment period for | 3 | | each category of risk of the vendor; and (iii) by rule, the | 4 | | hearing rights, if any, afforded to a vendor in each category | 5 | | of risk of the vendor that is terminated or disenrolled during | 6 | | the conditional enrollment period. | 7 | | To be eligible for payment consideration, a vendor's | 8 | | payment claim or bill, either as an initial claim or as a | 9 | | resubmitted claim following prior rejection, must be received | 10 | | by the Illinois Department, or its fiscal intermediary, no | 11 | | later than 180 days after the latest date on the claim on which | 12 | | medical goods or services were provided, with the following | 13 | | exceptions: | 14 | | (1) In the case of a provider whose enrollment is in | 15 | | process by the Illinois Department, the 180-day period | 16 | | shall not begin until the date on the written notice from | 17 | | the Illinois Department that the provider enrollment is | 18 | | complete. | 19 | | (2) In the case of errors attributable to the Illinois | 20 | | Department or any of its claims processing intermediaries | 21 | | which result in an inability to receive, process, or | 22 | | adjudicate a claim, the 180-day period shall not begin | 23 | | until the provider has been notified of the error. | 24 | | (3) In the case of a provider for whom the Illinois | 25 | | Department initiates the monthly billing process. | 26 | | (4) In the case of a provider operated by a unit of |
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| 1 | | local government with a population exceeding 3,000,000 | 2 | | when local government funds finance federal participation | 3 | | for claims payments. | 4 | | For claims for services rendered during a period for which | 5 | | a recipient received retroactive eligibility, claims must be | 6 | | filed within 180 days after the Department determines the | 7 | | applicant is eligible. For claims for which the Illinois | 8 | | Department is not the primary payer, claims must be submitted | 9 | | to the Illinois Department within 180 days after the final | 10 | | adjudication by the primary payer. | 11 | | In the case of long term care facilities, within 5 days of | 12 | | receipt by the facility of required prescreening information, | 13 | | data for new admissions shall be entered into the Medical | 14 | | Electronic Data Interchange (MEDI) or the Recipient | 15 | | Eligibility Verification (REV) System or successor system, and | 16 | | within 15 days of receipt by the facility of required | 17 | | prescreening information, admission documents shall be | 18 | | submitted through MEDI or REV or shall be submitted directly to | 19 | | the Department of Human Services using required admission | 20 | | forms. Effective September
1, 2014, admission documents, | 21 | | including all prescreening
information, must be submitted | 22 | | through MEDI or REV. Confirmation numbers assigned to an | 23 | | accepted transaction shall be retained by a facility to verify | 24 | | timely submittal. Once an admission transaction has been | 25 | | completed, all resubmitted claims following prior rejection | 26 | | are subject to receipt no later than 180 days after the |
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| 1 | | admission transaction has been completed. | 2 | | Claims that are not submitted and received in compliance | 3 | | with the foregoing requirements shall not be eligible for | 4 | | payment under the medical assistance program, and the State | 5 | | shall have no liability for payment of those claims. | 6 | | To the extent consistent with applicable information and | 7 | | privacy, security, and disclosure laws, State and federal | 8 | | agencies and departments shall provide the Illinois Department | 9 | | access to confidential and other information and data necessary | 10 | | to perform eligibility and payment verifications and other | 11 | | Illinois Department functions. This includes, but is not | 12 | | limited to: information pertaining to licensure; | 13 | | certification; earnings; immigration status; citizenship; wage | 14 | | reporting; unearned and earned income; pension income; | 15 | | employment; supplemental security income; social security | 16 | | numbers; National Provider Identifier (NPI) numbers; the | 17 | | National Practitioner Data Bank (NPDB); program and agency | 18 | | exclusions; taxpayer identification numbers; tax delinquency; | 19 | | corporate information; and death records. | 20 | | The Illinois Department shall enter into agreements with | 21 | | State agencies and departments, and is authorized to enter into | 22 | | agreements with federal agencies and departments, under which | 23 | | such agencies and departments shall share data necessary for | 24 | | medical assistance program integrity functions and oversight. | 25 | | The Illinois Department shall develop, in cooperation with | 26 | | other State departments and agencies, and in compliance with |
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| 1 | | applicable federal laws and regulations, appropriate and | 2 | | effective methods to share such data. At a minimum, and to the | 3 | | extent necessary to provide data sharing, the Illinois | 4 | | Department shall enter into agreements with State agencies and | 5 | | departments, and is authorized to enter into agreements with | 6 | | federal agencies and departments, including but not limited to: | 7 | | the Secretary of State; the Department of Revenue; the | 8 | | Department of Public Health; the Department of Human Services; | 9 | | and the Department of Financial and Professional Regulation. | 10 | | Beginning in fiscal year 2013, the Illinois Department | 11 | | shall set forth a request for information to identify the | 12 | | benefits of a pre-payment, post-adjudication, and post-edit | 13 | | claims system with the goals of streamlining claims processing | 14 | | and provider reimbursement, reducing the number of pending or | 15 | | rejected claims, and helping to ensure a more transparent | 16 | | adjudication process through the utilization of: (i) provider | 17 | | data verification and provider screening technology; and (ii) | 18 | | clinical code editing; and (iii) pre-pay, pre- or | 19 | | post-adjudicated predictive modeling with an integrated case | 20 | | management system with link analysis. Such a request for | 21 | | information shall not be considered as a request for proposal | 22 | | or as an obligation on the part of the Illinois Department to | 23 | | take any action or acquire any products or services. | 24 | | The Illinois Department shall establish policies, | 25 | | procedures,
standards and criteria by rule for the acquisition, | 26 | | repair and replacement
of orthotic and prosthetic devices and |
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| 1 | | durable medical equipment. Such
rules shall provide, but not be | 2 | | limited to, the following services: (1)
immediate repair or | 3 | | replacement of such devices by recipients; and (2) rental, | 4 | | lease, purchase or lease-purchase of
durable medical equipment | 5 | | in a cost-effective manner, taking into
consideration the | 6 | | recipient's medical prognosis, the extent of the
recipient's | 7 | | needs, and the requirements and costs for maintaining such
| 8 | | equipment. Subject to prior approval, such rules shall enable a | 9 | | recipient to temporarily acquire and
use alternative or | 10 | | substitute devices or equipment pending repairs or
| 11 | | replacements of any device or equipment previously authorized | 12 | | for such
recipient by the Department.
| 13 | | The Department shall execute, relative to the nursing home | 14 | | prescreening
project, written inter-agency agreements with the | 15 | | Department of Human
Services and the Department on Aging, to | 16 | | effect the following: (i) intake
procedures and common | 17 | | eligibility criteria for those persons who are receiving
| 18 | | non-institutional services; and (ii) the establishment and | 19 | | development of
non-institutional services in areas of the State | 20 | | where they are not currently
available or are undeveloped; and | 21 | | (iii) notwithstanding any other provision of law, subject to | 22 | | federal approval, on and after July 1, 2012, an increase in the | 23 | | determination of need (DON) scores from 29 to 37 for applicants | 24 | | for institutional and home and community-based long term care; | 25 | | if and only if federal approval is not granted, the Department | 26 | | may, in conjunction with other affected agencies, implement |
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| 1 | | utilization controls or changes in benefit packages to | 2 | | effectuate a similar savings amount for this population; and | 3 | | (iv) no later than July 1, 2013, minimum level of care | 4 | | eligibility criteria for institutional and home and | 5 | | community-based long term care; and (v) no later than October | 6 | | 1, 2013, establish procedures to permit long term care | 7 | | providers access to eligibility scores for individuals with an | 8 | | admission date who are seeking or receiving services from the | 9 | | long term care provider. In order to select the minimum level | 10 | | of care eligibility criteria, the Governor shall establish a | 11 | | workgroup that includes affected agency representatives and | 12 | | stakeholders representing the institutional and home and | 13 | | community-based long term care interests. This Section shall | 14 | | not restrict the Department from implementing lower level of | 15 | | care eligibility criteria for community-based services in | 16 | | circumstances where federal approval has been granted.
| 17 | | The Illinois Department shall develop and operate, in | 18 | | cooperation
with other State Departments and agencies and in | 19 | | compliance with
applicable federal laws and regulations, | 20 | | appropriate and effective
systems of health care evaluation and | 21 | | programs for monitoring of
utilization of health care services | 22 | | and facilities, as it affects
persons eligible for medical | 23 | | assistance under this Code.
| 24 | | The Illinois Department shall report annually to the | 25 | | General Assembly,
no later than the second Friday in April of | 26 | | 1979 and each year
thereafter, in regard to:
|
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| 1 | | (a) actual statistics and trends in utilization of | 2 | | medical services by
public aid recipients;
| 3 | | (b) actual statistics and trends in the provision of | 4 | | the various medical
services by medical vendors;
| 5 | | (c) current rate structures and proposed changes in | 6 | | those rate structures
for the various medical vendors; and
| 7 | | (d) efforts at utilization review and control by the | 8 | | Illinois Department.
| 9 | | The period covered by each report shall be the 3 years | 10 | | ending on the June
30 prior to the report. The report shall | 11 | | include suggested legislation
for consideration by the General | 12 | | Assembly. The filing of one copy of the
report with the | 13 | | Speaker, one copy with the Minority Leader and one copy
with | 14 | | the Clerk of the House of Representatives, one copy with the | 15 | | President,
one copy with the Minority Leader and one copy with | 16 | | the Secretary of the
Senate, one copy with the Legislative | 17 | | Research Unit, and such additional
copies
with the State | 18 | | Government Report Distribution Center for the General
Assembly | 19 | | as is required under paragraph (t) of Section 7 of the State
| 20 | | Library Act shall be deemed sufficient to comply with this | 21 | | Section.
| 22 | | Rulemaking authority to implement Public Act 95-1045, if | 23 | | any, is conditioned on the rules being adopted in accordance | 24 | | with all provisions of the Illinois Administrative Procedure | 25 | | Act and all rules and procedures of the Joint Committee on | 26 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | On and after July 1, 2012, the Department shall reduce any | 3 | | rate of reimbursement for services or other payments or alter | 4 | | any methodologies authorized by this Code to reduce any rate of | 5 | | reimbursement for services or other payments in accordance with | 6 | | Section 5-5e. | 7 | | Because kidney transplantation can be an appropriate, cost | 8 | | effective
alternative to renal dialysis when medically | 9 | | necessary and notwithstanding the provisions of Section 1-11 of | 10 | | this Code, beginning October 1, 2014, the Department shall | 11 | | cover kidney transplantation for noncitizens with end-stage | 12 | | renal disease who are not eligible for comprehensive medical | 13 | | benefits, who meet the residency requirements of Section 5-3 of | 14 | | this Code, and who would otherwise meet the financial | 15 | | requirements of the appropriate class of eligible persons under | 16 | | Section 5-2 of this Code. To qualify for coverage of kidney | 17 | | transplantation, such person must be receiving emergency renal | 18 | | dialysis services covered by the Department. Providers under | 19 | | this Section shall be prior approved and certified by the | 20 | | Department to perform kidney transplantation and the services | 21 | | under this Section shall be limited to services associated with | 22 | | kidney transplantation. | 23 | | Notwithstanding any other provision of this Code to the | 24 | | contrary, on or after July 1, 2015, all FDA approved forms of | 25 | | medication assisted treatment prescribed for the treatment of | 26 | | alcohol dependence or treatment of opioid dependence shall be |
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| 1 | | covered under both fee for service and managed care medical | 2 | | assistance programs for persons who are otherwise eligible for | 3 | | medical assistance under this Article and shall not be subject | 4 | | to any (1) utilization control, other than those established | 5 | | under the American Society of Addiction Medicine patient | 6 | | placement criteria,
(2) prior authorization mandate, or (3) | 7 | | lifetime restriction limit
mandate. | 8 | | On or after July 1, 2015, opioid antagonists prescribed for | 9 | | the treatment of an opioid overdose, including the medication | 10 | | product, administration devices, and any pharmacy fees related | 11 | | to the dispensing and administration of the opioid antagonist, | 12 | | shall be covered under the medical assistance program for | 13 | | persons who are otherwise eligible for medical assistance under | 14 | | this Article. As used in this Section, "opioid antagonist" | 15 | | means a drug that binds to opioid receptors and blocks or | 16 | | inhibits the effect of opioids acting on those receptors, | 17 | | including, but not limited to, naloxone hydrochloride or any | 18 | | other similarly acting drug approved by the U.S. Food and Drug | 19 | | Administration. | 20 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | 21 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | 22 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | 23 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | 24 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff. | 25 | | 8-21-15; 99-480, eff. 9-9-15; revised 10-13-15.) |
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| 1 | | (Text of Section after amendment by P.A. 99-407 ) | 2 | | Sec. 5-5. Medical services. The Illinois Department, by | 3 | | rule, shall
determine the quantity and quality of and the rate | 4 | | of reimbursement for the
medical assistance for which
payment | 5 | | will be authorized, and the medical services to be provided,
| 6 | | which may include all or part of the following: (1) inpatient | 7 | | hospital
services; (2) outpatient hospital services; (3) other | 8 | | laboratory and
X-ray services; (4) skilled nursing home | 9 | | services; (5) physicians'
services whether furnished in the | 10 | | office, the patient's home, a
hospital, a skilled nursing home, | 11 | | or elsewhere; (6) medical care, or any
other type of remedial | 12 | | care furnished by licensed practitioners; (7)
home health care | 13 | | services; (8) private duty nursing service; (9) clinic
| 14 | | services; (10) dental services, including prevention and | 15 | | treatment of periodontal disease and dental caries disease for | 16 | | pregnant women, provided by an individual licensed to practice | 17 | | dentistry or dental surgery; for purposes of this item (10), | 18 | | "dental services" means diagnostic, preventive, or corrective | 19 | | procedures provided by or under the supervision of a dentist in | 20 | | the practice of his or her profession; (11) physical therapy | 21 | | and related
services; (12) prescribed drugs, dentures, and | 22 | | prosthetic devices; and
eyeglasses prescribed by a physician | 23 | | skilled in the diseases of the eye,
or by an optometrist, | 24 | | whichever the person may select; (13) other
diagnostic, | 25 | | screening, preventive, and rehabilitative services, including | 26 | | to ensure that the individual's need for intervention or |
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| 1 | | treatment of mental disorders or substance use disorders or | 2 | | co-occurring mental health and substance use disorders is | 3 | | determined using a uniform screening, assessment, and | 4 | | evaluation process inclusive of criteria, for children and | 5 | | adults; for purposes of this item (13), a uniform screening, | 6 | | assessment, and evaluation process refers to a process that | 7 | | includes an appropriate evaluation and, as warranted, a | 8 | | referral; "uniform" does not mean the use of a singular | 9 | | instrument, tool, or process that all must utilize; (14)
| 10 | | transportation and such other expenses as may be necessary; | 11 | | (15) medical
treatment of sexual assault survivors, as defined | 12 | | in
Section 1a of the Sexual Assault Survivors Emergency | 13 | | Treatment Act, for
injuries sustained as a result of the sexual | 14 | | assault, including
examinations and laboratory tests to | 15 | | discover evidence which may be used in
criminal proceedings | 16 | | arising from the sexual assault; (16) the
diagnosis and | 17 | | treatment of sickle cell anemia; and (17)
any other medical | 18 | | care, and any other type of remedial care recognized
under the | 19 | | laws of this State, but not including abortions, or induced
| 20 | | miscarriages or premature births, unless, in the opinion of a | 21 | | physician,
such procedures are necessary for the preservation | 22 | | of the life of the
woman seeking such treatment, or except an | 23 | | induced premature birth
intended to produce a live viable child | 24 | | and such procedure is necessary
for the health of the mother or | 25 | | her unborn child. The Illinois Department,
by rule, shall | 26 | | prohibit any physician from providing medical assistance
to |
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| 1 | | anyone eligible therefor under this Code where such physician | 2 | | has been
found guilty of performing an abortion procedure in a | 3 | | wilful and wanton
manner upon a woman who was not pregnant at | 4 | | the time such abortion
procedure was performed. The term "any | 5 | | other type of remedial care" shall
include nursing care and | 6 | | nursing home service for persons who rely on
treatment by | 7 | | spiritual means alone through prayer for healing.
| 8 | | Notwithstanding any other provision of this Section, a | 9 | | comprehensive
tobacco use cessation program that includes | 10 | | purchasing prescription drugs or
prescription medical devices | 11 | | approved by the Food and Drug Administration shall
be covered | 12 | | under the medical assistance
program under this Article for | 13 | | persons who are otherwise eligible for
assistance under this | 14 | | Article.
| 15 | | Notwithstanding any other provision of this Code, the | 16 | | Illinois
Department may not require, as a condition of payment | 17 | | for any laboratory
test authorized under this Article, that a | 18 | | physician's handwritten signature
appear on the laboratory | 19 | | test order form. The Illinois Department may,
however, impose | 20 | | other appropriate requirements regarding laboratory test
order | 21 | | documentation.
| 22 | | Upon receipt of federal approval of an amendment to the | 23 | | Illinois Title XIX State Plan for this purpose, the Department | 24 | | shall authorize the Chicago Public Schools (CPS) to procure a | 25 | | vendor or vendors to manufacture eyeglasses for individuals | 26 | | enrolled in a school within the CPS system. CPS shall ensure |
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| 1 | | that its vendor or vendors are enrolled as providers in the | 2 | | medical assistance program and in any capitated Medicaid | 3 | | managed care entity (MCE) serving individuals enrolled in a | 4 | | school within the CPS system. Under any contract procured under | 5 | | this provision, the vendor or vendors must serve only | 6 | | individuals enrolled in a school within the CPS system. Claims | 7 | | for services provided by CPS's vendor or vendors to recipients | 8 | | of benefits in the medical assistance program under this Code, | 9 | | the Children's Health Insurance Program, or the Covering ALL | 10 | | KIDS Health Insurance Program shall be submitted to the | 11 | | Department or the MCE in which the individual is enrolled for | 12 | | payment and shall be reimbursed at the Department's or the | 13 | | MCE's established rates or rate methodologies for eyeglasses. | 14 | | On and after July 1, 2012, the Department of Healthcare and | 15 | | Family Services may provide the following services to
persons
| 16 | | eligible for assistance under this Article who are | 17 | | participating in
education, training or employment programs | 18 | | operated by the Department of Human
Services as successor to | 19 | | the Department of Public Aid:
| 20 | | (1) dental services provided by or under the | 21 | | supervision of a dentist; and
| 22 | | (2) eyeglasses prescribed by a physician skilled in the | 23 | | diseases of the
eye, or by an optometrist, whichever the | 24 | | person may select.
| 25 | | Notwithstanding any other provision of this Code and | 26 | | subject to federal approval, the Department may adopt rules to |
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| 1 | | allow a dentist who is volunteering his or her service at no | 2 | | cost to render dental services through an enrolled | 3 | | not-for-profit health clinic without the dentist personally | 4 | | enrolling as a participating provider in the medical assistance | 5 | | program. A not-for-profit health clinic shall include a public | 6 | | health clinic or Federally Qualified Health Center or other | 7 | | enrolled provider, as determined by the Department, through | 8 | | which dental services covered under this Section are performed. | 9 | | The Department shall establish a process for payment of claims | 10 | | for reimbursement for covered dental services rendered under | 11 | | this provision. | 12 | | The Illinois Department, by rule, may distinguish and | 13 | | classify the
medical services to be provided only in accordance | 14 | | with the classes of
persons designated in Section 5-2.
| 15 | | The Department of Healthcare and Family Services must | 16 | | provide coverage and reimbursement for amino acid-based | 17 | | elemental formulas, regardless of delivery method, for the | 18 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 19 | | short bowel syndrome when the prescribing physician has issued | 20 | | a written order stating that the amino acid-based elemental | 21 | | formula is medically necessary.
| 22 | | The Illinois Department shall authorize the provision of, | 23 | | and shall
authorize payment for, screening by low-dose | 24 | | mammography for the presence of
occult breast cancer for women | 25 | | 35 years of age or older who are eligible
for medical | 26 | | assistance under this Article, as follows: |
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| 1 | | (A) A baseline
mammogram for women 35 to 39 years of | 2 | | age.
| 3 | | (B) An annual mammogram for women 40 years of age or | 4 | | older. | 5 | | (C) A mammogram at the age and intervals considered | 6 | | medically necessary by the woman's health care provider for | 7 | | women under 40 years of age and having a family history of | 8 | | breast cancer, prior personal history of breast cancer, | 9 | | positive genetic testing, or other risk factors. | 10 | | (D) A comprehensive ultrasound screening of an entire | 11 | | breast or breasts if a mammogram demonstrates | 12 | | heterogeneous or dense breast tissue, when medically | 13 | | necessary as determined by a physician licensed to practice | 14 | | medicine in all of its branches. | 15 | | (E) A screening MRI when medically necessary, as | 16 | | determined by a physician licensed to practice medicine in | 17 | | all of its branches. | 18 | | All screenings
shall
include a physical breast exam, | 19 | | instruction on self-examination and
information regarding the | 20 | | frequency of self-examination and its value as a
preventative | 21 | | tool. For purposes of this Section, "low-dose mammography" | 22 | | means
the x-ray examination of the breast using equipment | 23 | | dedicated specifically
for mammography, including the x-ray | 24 | | tube, filter, compression device,
and image receptor, with an | 25 | | average radiation exposure delivery
of less than one rad per | 26 | | breast for 2 views of an average size breast.
The term also |
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| 1 | | includes digital mammography and includes breast | 2 | | tomosynthesis. As used in this Section, the term "breast | 3 | | tomosynthesis" means a radiologic procedure that involves the | 4 | | acquisition of projection images over the stationary breast to | 5 | | produce cross-sectional digital three-dimensional images of | 6 | | the breast. If, at any time, the Secretary of the United States | 7 | | Department of Health and Human Services, or its successor | 8 | | agency, promulgates rules or regulations to be published in the | 9 | | Federal Register or publishes a comment in the Federal Register | 10 | | or issues an opinion, guidance, or other action that would | 11 | | require the State, pursuant to any provision of the Patient | 12 | | Protection and Affordable Care Act (Public Law 111-148), | 13 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 14 | | successor provision, to defray the cost of any coverage for | 15 | | breast tomosynthesis outlined in this paragraph, then the | 16 | | requirement that an insurer cover breast tomosynthesis is | 17 | | inoperative other than any such coverage authorized under | 18 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 19 | | the State shall not assume any obligation for the cost of | 20 | | coverage for breast tomosynthesis set forth in this paragraph.
| 21 | | On and after January 1, 2016, the Department shall ensure | 22 | | that all networks of care for adult clients of the Department | 23 | | include access to at least one breast imaging Center of Imaging | 24 | | Excellence as certified by the American College of Radiology. | 25 | | On and after January 1, 2012, providers participating in a | 26 | | quality improvement program approved by the Department shall be |
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| 1 | | reimbursed for screening and diagnostic mammography at the same | 2 | | rate as the Medicare program's rates, including the increased | 3 | | reimbursement for digital mammography. | 4 | | The Department shall convene an expert panel including | 5 | | representatives of hospitals, free-standing mammography | 6 | | facilities, and doctors, including radiologists, to establish | 7 | | quality standards for mammography. | 8 | | On and after January 1, 2017, providers participating in a | 9 | | breast cancer treatment quality improvement program approved | 10 | | by the Department shall be reimbursed for breast cancer | 11 | | treatment at a rate that is no lower than 95% of the Medicare | 12 | | program's rates for the data elements included in the breast | 13 | | cancer treatment quality program. | 14 | | The Department shall convene an expert panel, including | 15 | | representatives of hospitals, free standing breast cancer | 16 | | treatment centers, breast cancer quality organizations, and | 17 | | doctors, including breast surgeons, reconstructive breast | 18 | | surgeons, oncologists, and primary care providers to establish | 19 | | quality standards for breast cancer treatment. | 20 | | Subject to federal approval, the Department shall | 21 | | establish a rate methodology for mammography at federally | 22 | | qualified health centers and other encounter-rate clinics. | 23 | | These clinics or centers may also collaborate with other | 24 | | hospital-based mammography facilities. By January 1, 2016, the | 25 | | Department shall report to the General Assembly on the status | 26 | | of the provision set forth in this paragraph. |
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| 1 | | The Department shall establish a methodology to remind | 2 | | women who are age-appropriate for screening mammography, but | 3 | | who have not received a mammogram within the previous 18 | 4 | | months, of the importance and benefit of screening mammography. | 5 | | The Department shall work with experts in breast cancer | 6 | | outreach and patient navigation to optimize these reminders and | 7 | | shall establish a methodology for evaluating their | 8 | | effectiveness and modifying the methodology based on the | 9 | | evaluation. | 10 | | The Department shall establish a performance goal for | 11 | | primary care providers with respect to their female patients | 12 | | over age 40 receiving an annual mammogram. This performance | 13 | | goal shall be used to provide additional reimbursement in the | 14 | | form of a quality performance bonus to primary care providers | 15 | | who meet that goal. | 16 | | The Department shall devise a means of case-managing or | 17 | | patient navigation for beneficiaries diagnosed with breast | 18 | | cancer. This program shall initially operate as a pilot program | 19 | | in areas of the State with the highest incidence of mortality | 20 | | related to breast cancer. At least one pilot program site shall | 21 | | be in the metropolitan Chicago area and at least one site shall | 22 | | be outside the metropolitan Chicago area. On or after July 1, | 23 | | 2016, the pilot program shall be expanded to include one site | 24 | | in western Illinois, one site in southern Illinois, one site in | 25 | | central Illinois, and 4 sites within metropolitan Chicago. An | 26 | | evaluation of the pilot program shall be carried out measuring |
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| 1 | | health outcomes and cost of care for those served by the pilot | 2 | | program compared to similarly situated patients who are not | 3 | | served by the pilot program. | 4 | | The Department shall require all networks of care to | 5 | | develop a means either internally or by contract with experts | 6 | | in navigation and community outreach to navigate cancer | 7 | | patients to comprehensive care in a timely fashion. The | 8 | | Department shall require all networks of care to include access | 9 | | for patients diagnosed with cancer to at least one academic | 10 | | commission on cancer-accredited cancer program as an | 11 | | in-network covered benefit. | 12 | | Any medical or health care provider shall immediately | 13 | | recommend, to
any pregnant woman who is being provided prenatal | 14 | | services and is suspected
of drug abuse or is addicted as | 15 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 16 | | Act, referral to a local substance abuse treatment provider
| 17 | | licensed by the Department of Human Services or to a licensed
| 18 | | hospital which provides substance abuse treatment services. | 19 | | The Department of Healthcare and Family Services
shall assure | 20 | | coverage for the cost of treatment of the drug abuse or
| 21 | | addiction for pregnant recipients in accordance with the | 22 | | Illinois Medicaid
Program in conjunction with the Department of | 23 | | Human Services.
| 24 | | All medical providers providing medical assistance to | 25 | | pregnant women
under this Code shall receive information from | 26 | | the Department on the
availability of services under the Drug |
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| 1 | | Free Families with a Future or any
comparable program providing | 2 | | case management services for addicted women,
including | 3 | | information on appropriate referrals for other social services
| 4 | | that may be needed by addicted women in addition to treatment | 5 | | for addiction.
| 6 | | The Illinois Department, in cooperation with the | 7 | | Departments of Human
Services (as successor to the Department | 8 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 9 | | public awareness campaign, may
provide information concerning | 10 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 11 | | health care, and other pertinent programs directed at
reducing | 12 | | the number of drug-affected infants born to recipients of | 13 | | medical
assistance.
| 14 | | Neither the Department of Healthcare and Family Services | 15 | | nor the Department of Human
Services shall sanction the | 16 | | recipient solely on the basis of
her substance abuse.
| 17 | | The Illinois Department shall establish such regulations | 18 | | governing
the dispensing of health services under this Article | 19 | | as it shall deem
appropriate. The Department
should
seek the | 20 | | advice of formal professional advisory committees appointed by
| 21 | | the Director of the Illinois Department for the purpose of | 22 | | providing regular
advice on policy and administrative matters, | 23 | | information dissemination and
educational activities for | 24 | | medical and health care providers, and
consistency in | 25 | | procedures to the Illinois Department.
| 26 | | The Illinois Department may develop and contract with |
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| 1 | | Partnerships of
medical providers to arrange medical services | 2 | | for persons eligible under
Section 5-2 of this Code. | 3 | | Implementation of this Section may be by
demonstration projects | 4 | | in certain geographic areas. The Partnership shall
be | 5 | | represented by a sponsor organization. The Department, by rule, | 6 | | shall
develop qualifications for sponsors of Partnerships. | 7 | | Nothing in this
Section shall be construed to require that the | 8 | | sponsor organization be a
medical organization.
| 9 | | The sponsor must negotiate formal written contracts with | 10 | | medical
providers for physician services, inpatient and | 11 | | outpatient hospital care,
home health services, treatment for | 12 | | alcoholism and substance abuse, and
other services determined | 13 | | necessary by the Illinois Department by rule for
delivery by | 14 | | Partnerships. Physician services must include prenatal and
| 15 | | obstetrical care. The Illinois Department shall reimburse | 16 | | medical services
delivered by Partnership providers to clients | 17 | | in target areas according to
provisions of this Article and the | 18 | | Illinois Health Finance Reform Act,
except that:
| 19 | | (1) Physicians participating in a Partnership and | 20 | | providing certain
services, which shall be determined by | 21 | | the Illinois Department, to persons
in areas covered by the | 22 | | Partnership may receive an additional surcharge
for such | 23 | | services.
| 24 | | (2) The Department may elect to consider and negotiate | 25 | | financial
incentives to encourage the development of | 26 | | Partnerships and the efficient
delivery of medical care.
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| 1 | | (3) Persons receiving medical services through | 2 | | Partnerships may receive
medical and case management | 3 | | services above the level usually offered
through the | 4 | | medical assistance program.
| 5 | | Medical providers shall be required to meet certain | 6 | | qualifications to
participate in Partnerships to ensure the | 7 | | delivery of high quality medical
services. These | 8 | | qualifications shall be determined by rule of the Illinois
| 9 | | Department and may be higher than qualifications for | 10 | | participation in the
medical assistance program. Partnership | 11 | | sponsors may prescribe reasonable
additional qualifications | 12 | | for participation by medical providers, only with
the prior | 13 | | written approval of the Illinois Department.
| 14 | | Nothing in this Section shall limit the free choice of | 15 | | practitioners,
hospitals, and other providers of medical | 16 | | services by clients.
In order to ensure patient freedom of | 17 | | choice, the Illinois Department shall
immediately promulgate | 18 | | all rules and take all other necessary actions so that
provided | 19 | | services may be accessed from therapeutically certified | 20 | | optometrists
to the full extent of the Illinois Optometric | 21 | | Practice Act of 1987 without
discriminating between service | 22 | | providers.
| 23 | | The Department shall apply for a waiver from the United | 24 | | States Health
Care Financing Administration to allow for the | 25 | | implementation of
Partnerships under this Section.
| 26 | | The Illinois Department shall require health care |
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| 1 | | providers to maintain
records that document the medical care | 2 | | and services provided to recipients
of Medical Assistance under | 3 | | this Article. Such records must be retained for a period of not | 4 | | less than 6 years from the date of service or as provided by | 5 | | applicable State law, whichever period is longer, except that | 6 | | if an audit is initiated within the required retention period | 7 | | then the records must be retained until the audit is completed | 8 | | and every exception is resolved. The Illinois Department shall
| 9 | | require health care providers to make available, when | 10 | | authorized by the
patient, in writing, the medical records in a | 11 | | timely fashion to other
health care providers who are treating | 12 | | or serving persons eligible for
Medical Assistance under this | 13 | | Article. All dispensers of medical services
shall be required | 14 | | to maintain and retain business and professional records
| 15 | | sufficient to fully and accurately document the nature, scope, | 16 | | details and
receipt of the health care provided to persons | 17 | | eligible for medical
assistance under this Code, in accordance | 18 | | with regulations promulgated by
the Illinois Department. The | 19 | | rules and regulations shall require that proof
of the receipt | 20 | | of prescription drugs, dentures, prosthetic devices and
| 21 | | eyeglasses by eligible persons under this Section accompany | 22 | | each claim
for reimbursement submitted by the dispenser of such | 23 | | medical services.
No such claims for reimbursement shall be | 24 | | approved for payment by the Illinois
Department without such | 25 | | proof of receipt, unless the Illinois Department
shall have put | 26 | | into effect and shall be operating a system of post-payment
|
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| 1 | | audit and review which shall, on a sampling basis, be deemed | 2 | | adequate by
the Illinois Department to assure that such drugs, | 3 | | dentures, prosthetic
devices and eyeglasses for which payment | 4 | | is being made are actually being
received by eligible | 5 | | recipients. Within 90 days after September 16, 1984 ( the | 6 | | effective date of Public Act 83-1439)
this amendatory Act of | 7 | | 1984 , the Illinois Department shall establish a
current list of | 8 | | acquisition costs for all prosthetic devices and any
other | 9 | | items recognized as medical equipment and supplies | 10 | | reimbursable under
this Article and shall update such list on a | 11 | | quarterly basis, except that
the acquisition costs of all | 12 | | prescription drugs shall be updated no
less frequently than | 13 | | every 30 days as required by Section 5-5.12.
| 14 | | The rules and regulations of the Illinois Department shall | 15 | | require
that a written statement including the required opinion | 16 | | of a physician
shall accompany any claim for reimbursement for | 17 | | abortions, or induced
miscarriages or premature births. This | 18 | | statement shall indicate what
procedures were used in providing | 19 | | such medical services.
| 20 | | Notwithstanding any other law to the contrary, the Illinois | 21 | | Department shall, within 365 days after July 22, 2013 (the | 22 | | effective date of Public Act 98-104), establish procedures to | 23 | | permit skilled care facilities licensed under the Nursing Home | 24 | | Care Act to submit monthly billing claims for reimbursement | 25 | | purposes. Following development of these procedures, the | 26 | | Department shall, by July 1, 2016, test the viability of the |
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| 1 | | new system and implement any necessary operational or | 2 | | structural changes to its information technology platforms in | 3 | | order to allow for the direct acceptance and payment of nursing | 4 | | home claims. | 5 | | Notwithstanding any other law to the contrary, the Illinois | 6 | | Department shall, within 365 days after August 15, 2014 (the | 7 | | effective date of Public Act 98-963), establish procedures to | 8 | | permit ID/DD facilities licensed under the ID/DD Community Care | 9 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 10 | | monthly billing claims for reimbursement purposes. Following | 11 | | development of these procedures, the Department shall have an | 12 | | additional 365 days to test the viability of the new system and | 13 | | to ensure that any necessary operational or structural changes | 14 | | to its information technology platforms are implemented. | 15 | | The Illinois Department shall require all dispensers of | 16 | | medical
services, other than an individual practitioner or | 17 | | group of practitioners,
desiring to participate in the Medical | 18 | | Assistance program
established under this Article to disclose | 19 | | all financial, beneficial,
ownership, equity, surety or other | 20 | | interests in any and all firms,
corporations, partnerships, | 21 | | associations, business enterprises, joint
ventures, agencies, | 22 | | institutions or other legal entities providing any
form of | 23 | | health care services in this State under this Article.
| 24 | | The Illinois Department may require that all dispensers of | 25 | | medical
services desiring to participate in the medical | 26 | | assistance program
established under this Article disclose, |
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| 1 | | under such terms and conditions as
the Illinois Department may | 2 | | by rule establish, all inquiries from clients
and attorneys | 3 | | regarding medical bills paid by the Illinois Department, which
| 4 | | inquiries could indicate potential existence of claims or liens | 5 | | for the
Illinois Department.
| 6 | | Enrollment of a vendor
shall be
subject to a provisional | 7 | | period and shall be conditional for one year. During the period | 8 | | of conditional enrollment, the Department may
terminate the | 9 | | vendor's eligibility to participate in, or may disenroll the | 10 | | vendor from, the medical assistance
program without cause. | 11 | | Unless otherwise specified, such termination of eligibility or | 12 | | disenrollment is not subject to the
Department's hearing | 13 | | process.
However, a disenrolled vendor may reapply without | 14 | | penalty.
| 15 | | The Department has the discretion to limit the conditional | 16 | | enrollment period for vendors based upon category of risk of | 17 | | the vendor. | 18 | | Prior to enrollment and during the conditional enrollment | 19 | | period in the medical assistance program, all vendors shall be | 20 | | subject to enhanced oversight, screening, and review based on | 21 | | the risk of fraud, waste, and abuse that is posed by the | 22 | | category of risk of the vendor. The Illinois Department shall | 23 | | establish the procedures for oversight, screening, and review, | 24 | | which may include, but need not be limited to: criminal and | 25 | | financial background checks; fingerprinting; license, | 26 | | certification, and authorization verifications; unscheduled or |
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| 1 | | unannounced site visits; database checks; prepayment audit | 2 | | reviews; audits; payment caps; payment suspensions; and other | 3 | | screening as required by federal or State law. | 4 | | The Department shall define or specify the following: (i) | 5 | | by provider notice, the "category of risk of the vendor" for | 6 | | each type of vendor, which shall take into account the level of | 7 | | screening applicable to a particular category of vendor under | 8 | | federal law and regulations; (ii) by rule or provider notice, | 9 | | the maximum length of the conditional enrollment period for | 10 | | each category of risk of the vendor; and (iii) by rule, the | 11 | | hearing rights, if any, afforded to a vendor in each category | 12 | | of risk of the vendor that is terminated or disenrolled during | 13 | | the conditional enrollment period. | 14 | | To be eligible for payment consideration, a vendor's | 15 | | payment claim or bill, either as an initial claim or as a | 16 | | resubmitted claim following prior rejection, must be received | 17 | | by the Illinois Department, or its fiscal intermediary, no | 18 | | later than 180 days after the latest date on the claim on which | 19 | | medical goods or services were provided, with the following | 20 | | exceptions: | 21 | | (1) In the case of a provider whose enrollment is in | 22 | | process by the Illinois Department, the 180-day period | 23 | | shall not begin until the date on the written notice from | 24 | | the Illinois Department that the provider enrollment is | 25 | | complete. | 26 | | (2) In the case of errors attributable to the Illinois |
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| 1 | | Department or any of its claims processing intermediaries | 2 | | which result in an inability to receive, process, or | 3 | | adjudicate a claim, the 180-day period shall not begin | 4 | | until the provider has been notified of the error. | 5 | | (3) In the case of a provider for whom the Illinois | 6 | | Department initiates the monthly billing process. | 7 | | (4) In the case of a provider operated by a unit of | 8 | | local government with a population exceeding 3,000,000 | 9 | | when local government funds finance federal participation | 10 | | for claims payments. | 11 | | For claims for services rendered during a period for which | 12 | | a recipient received retroactive eligibility, claims must be | 13 | | filed within 180 days after the Department determines the | 14 | | applicant is eligible. For claims for which the Illinois | 15 | | Department is not the primary payer, claims must be submitted | 16 | | to the Illinois Department within 180 days after the final | 17 | | adjudication by the primary payer. | 18 | | In the case of long term care facilities, within 5 days of | 19 | | receipt by the facility of required prescreening information, | 20 | | data for new admissions shall be entered into the Medical | 21 | | Electronic Data Interchange (MEDI) or the Recipient | 22 | | Eligibility Verification (REV) System or successor system, and | 23 | | within 15 days of receipt by the facility of required | 24 | | prescreening information, admission documents shall be | 25 | | submitted through MEDI or REV or shall be submitted directly to | 26 | | the Department of Human Services using required admission |
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| 1 | | forms. Effective September
1, 2014, admission documents, | 2 | | including all prescreening
information, must be submitted | 3 | | through MEDI or REV. Confirmation numbers assigned to an | 4 | | accepted transaction shall be retained by a facility to verify | 5 | | timely submittal. Once an admission transaction has been | 6 | | completed, all resubmitted claims following prior rejection | 7 | | are subject to receipt no later than 180 days after the | 8 | | admission transaction has been completed. | 9 | | Claims that are not submitted and received in compliance | 10 | | with the foregoing requirements shall not be eligible for | 11 | | payment under the medical assistance program, and the State | 12 | | shall have no liability for payment of those claims. | 13 | | To the extent consistent with applicable information and | 14 | | privacy, security, and disclosure laws, State and federal | 15 | | agencies and departments shall provide the Illinois Department | 16 | | access to confidential and other information and data necessary | 17 | | to perform eligibility and payment verifications and other | 18 | | Illinois Department functions. This includes, but is not | 19 | | limited to: information pertaining to licensure; | 20 | | certification; earnings; immigration status; citizenship; wage | 21 | | reporting; unearned and earned income; pension income; | 22 | | employment; supplemental security income; social security | 23 | | numbers; National Provider Identifier (NPI) numbers; the | 24 | | National Practitioner Data Bank (NPDB); program and agency | 25 | | exclusions; taxpayer identification numbers; tax delinquency; | 26 | | corporate information; and death records. |
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| 1 | | The Illinois Department shall enter into agreements with | 2 | | State agencies and departments, and is authorized to enter into | 3 | | agreements with federal agencies and departments, under which | 4 | | such agencies and departments shall share data necessary for | 5 | | medical assistance program integrity functions and oversight. | 6 | | The Illinois Department shall develop, in cooperation with | 7 | | other State departments and agencies, and in compliance with | 8 | | applicable federal laws and regulations, appropriate and | 9 | | effective methods to share such data. At a minimum, and to the | 10 | | extent necessary to provide data sharing, the Illinois | 11 | | Department shall enter into agreements with State agencies and | 12 | | departments, and is authorized to enter into agreements with | 13 | | federal agencies and departments, including but not limited to: | 14 | | the Secretary of State; the Department of Revenue; the | 15 | | Department of Public Health; the Department of Human Services; | 16 | | and the Department of Financial and Professional Regulation. | 17 | | Beginning in fiscal year 2013, the Illinois Department | 18 | | shall set forth a request for information to identify the | 19 | | benefits of a pre-payment, post-adjudication, and post-edit | 20 | | claims system with the goals of streamlining claims processing | 21 | | and provider reimbursement, reducing the number of pending or | 22 | | rejected claims, and helping to ensure a more transparent | 23 | | adjudication process through the utilization of: (i) provider | 24 | | data verification and provider screening technology; and (ii) | 25 | | clinical code editing; and (iii) pre-pay, pre- or | 26 | | post-adjudicated predictive modeling with an integrated case |
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| 1 | | management system with link analysis. Such a request for | 2 | | information shall not be considered as a request for proposal | 3 | | or as an obligation on the part of the Illinois Department to | 4 | | take any action or acquire any products or services. | 5 | | The Illinois Department shall establish policies, | 6 | | procedures,
standards and criteria by rule for the acquisition, | 7 | | repair and replacement
of orthotic and prosthetic devices and | 8 | | durable medical equipment. Such
rules shall provide, but not be | 9 | | limited to, the following services: (1)
immediate repair or | 10 | | replacement of such devices by recipients; and (2) rental, | 11 | | lease, purchase or lease-purchase of
durable medical equipment | 12 | | in a cost-effective manner, taking into
consideration the | 13 | | recipient's medical prognosis, the extent of the
recipient's | 14 | | needs, and the requirements and costs for maintaining such
| 15 | | equipment. Subject to prior approval, such rules shall enable a | 16 | | recipient to temporarily acquire and
use alternative or | 17 | | substitute devices or equipment pending repairs or
| 18 | | replacements of any device or equipment previously authorized | 19 | | for such
recipient by the Department.
| 20 | | The Department shall execute, relative to the nursing home | 21 | | prescreening
project, written inter-agency agreements with the | 22 | | Department of Human
Services and the Department on Aging, to | 23 | | effect the following: (i) intake
procedures and common | 24 | | eligibility criteria for those persons who are receiving
| 25 | | non-institutional services; and (ii) the establishment and | 26 | | development of
non-institutional services in areas of the State |
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| 1 | | where they are not currently
available or are undeveloped; and | 2 | | (iii) notwithstanding any other provision of law, subject to | 3 | | federal approval, on and after July 1, 2012, an increase in the | 4 | | determination of need (DON) scores from 29 to 37 for applicants | 5 | | for institutional and home and community-based long term care; | 6 | | if and only if federal approval is not granted, the Department | 7 | | may, in conjunction with other affected agencies, implement | 8 | | utilization controls or changes in benefit packages to | 9 | | effectuate a similar savings amount for this population; and | 10 | | (iv) no later than July 1, 2013, minimum level of care | 11 | | eligibility criteria for institutional and home and | 12 | | community-based long term care; and (v) no later than October | 13 | | 1, 2013, establish procedures to permit long term care | 14 | | providers access to eligibility scores for individuals with an | 15 | | admission date who are seeking or receiving services from the | 16 | | long term care provider. In order to select the minimum level | 17 | | of care eligibility criteria, the Governor shall establish a | 18 | | workgroup that includes affected agency representatives and | 19 | | stakeholders representing the institutional and home and | 20 | | community-based long term care interests. This Section shall | 21 | | not restrict the Department from implementing lower level of | 22 | | care eligibility criteria for community-based services in | 23 | | circumstances where federal approval has been granted.
| 24 | | The Illinois Department shall develop and operate, in | 25 | | cooperation
with other State Departments and agencies and in | 26 | | compliance with
applicable federal laws and regulations, |
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| 1 | | appropriate and effective
systems of health care evaluation and | 2 | | programs for monitoring of
utilization of health care services | 3 | | and facilities, as it affects
persons eligible for medical | 4 | | assistance under this Code.
| 5 | | The Illinois Department shall report annually to the | 6 | | General Assembly,
no later than the second Friday in April of | 7 | | 1979 and each year
thereafter, in regard to:
| 8 | | (a) actual statistics and trends in utilization of | 9 | | medical services by
public aid recipients;
| 10 | | (b) actual statistics and trends in the provision of | 11 | | the various medical
services by medical vendors;
| 12 | | (c) current rate structures and proposed changes in | 13 | | those rate structures
for the various medical vendors; and
| 14 | | (d) efforts at utilization review and control by the | 15 | | Illinois Department.
| 16 | | The period covered by each report shall be the 3 years | 17 | | ending on the June
30 prior to the report. The report shall | 18 | | include suggested legislation
for consideration by the General | 19 | | Assembly. The filing of one copy of the
report with the | 20 | | Speaker, one copy with the Minority Leader and one copy
with | 21 | | the Clerk of the House of Representatives, one copy with the | 22 | | President,
one copy with the Minority Leader and one copy with | 23 | | the Secretary of the
Senate, one copy with the Legislative | 24 | | Research Unit, and such additional
copies
with the State | 25 | | Government Report Distribution Center for the General
Assembly | 26 | | as is required under paragraph (t) of Section 7 of the State
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| 1 | | Library Act shall be deemed sufficient to comply with this | 2 | | Section.
| 3 | | Rulemaking authority to implement Public Act 95-1045, if | 4 | | any, is conditioned on the rules being adopted in accordance | 5 | | with all provisions of the Illinois Administrative Procedure | 6 | | Act and all rules and procedures of the Joint Committee on | 7 | | Administrative Rules; any purported rule not so adopted, for | 8 | | whatever reason, is unauthorized. | 9 | | On and after July 1, 2012, the Department shall reduce any | 10 | | rate of reimbursement for services or other payments or alter | 11 | | any methodologies authorized by this Code to reduce any rate of | 12 | | reimbursement for services or other payments in accordance with | 13 | | Section 5-5e. | 14 | | Because kidney transplantation can be an appropriate, cost | 15 | | effective
alternative to renal dialysis when medically | 16 | | necessary and notwithstanding the provisions of Section 1-11 of | 17 | | this Code, beginning October 1, 2014, the Department shall | 18 | | cover kidney transplantation for noncitizens with end-stage | 19 | | renal disease who are not eligible for comprehensive medical | 20 | | benefits, who meet the residency requirements of Section 5-3 of | 21 | | this Code, and who would otherwise meet the financial | 22 | | requirements of the appropriate class of eligible persons under | 23 | | Section 5-2 of this Code. To qualify for coverage of kidney | 24 | | transplantation, such person must be receiving emergency renal | 25 | | dialysis services covered by the Department. Providers under | 26 | | this Section shall be prior approved and certified by the |
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| 1 | | Department to perform kidney transplantation and the services | 2 | | under this Section shall be limited to services associated with | 3 | | kidney transplantation. | 4 | | Notwithstanding any other provision of this Code to the | 5 | | contrary, on or after July 1, 2015, all FDA approved forms of | 6 | | medication assisted treatment prescribed for the treatment of | 7 | | alcohol dependence or treatment of opioid dependence shall be | 8 | | covered under both fee for service and managed care medical | 9 | | assistance programs for persons who are otherwise eligible for | 10 | | medical assistance under this Article and shall not be subject | 11 | | to any (1) utilization control, other than those established | 12 | | under the American Society of Addiction Medicine patient | 13 | | placement criteria,
(2) prior authorization mandate, or (3) | 14 | | lifetime restriction limit
mandate. | 15 | | On or after July 1, 2015, opioid antagonists prescribed for | 16 | | the treatment of an opioid overdose, including the medication | 17 | | product, administration devices, and any pharmacy fees related | 18 | | to the dispensing and administration of the opioid antagonist, | 19 | | shall be covered under the medical assistance program for | 20 | | persons who are otherwise eligible for medical assistance under | 21 | | this Article. As used in this Section, "opioid antagonist" | 22 | | means a drug that binds to opioid receptors and blocks or | 23 | | inhibits the effect of opioids acting on those receptors, | 24 | | including, but not limited to, naloxone hydrochloride or any | 25 | | other similarly acting drug approved by the U.S. Food and Drug | 26 | | Administration. |
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| 1 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | 2 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | 3 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | 4 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | 5 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section | 6 | | 99 of P.A. 99-407 for its effective date); 99-433, eff. | 7 | | 8-21-15; 99-480, eff. 9-9-15; revised 10-13-15.) | 8 | | Section 20. "An Act concerning regulation", approved | 9 | | August 19, 2015, Public Act 99-407, is amended by changing | 10 | | Section 99 as follows: | 11 | | (P.A. 99-407, Sec. 99)
| 12 | | Sec. 99. Effective date. This Act takes effect on July 1, | 13 | | 2016 . , if and only if on or before July 1, 2016: | 14 | | (1) the Secretary of the United States Department of Health | 15 | | and Human Services, or its successor agency, promulgates rules | 16 | | or regulations published in the Federal Register or publishes a | 17 | | comment in the Federal Register: | 18 | | (A) repealing, amending, or reinterpreting 45 CFR | 19 | | 155.170 to eliminate the State's responsibility to defray | 20 | | the cost of a state-mandated benefit enacted on or after | 21 | | January 1, 2012; | 22 | | (B) requiring qualified health plans, as defined in the | 23 | | federal Patient Protection and Affordable Care Act, as | 24 | | amended by the Health Care and Education Reconciliation Act |
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| 1 | | of 2010 and any subsequent amendatory Acts, rules, or | 2 | | regulations issued pursuant thereto, to cover breast | 3 | | tomosynthesis as an essential health benefit; or | 4 | | (C) including breast tomosynthesis as a standard as | 5 | | part of the essential health benefits required of benchmark | 6 | | plans under 45 CFR 156.110; or | 7 | | (2) the federal Patient Protection and Affordable Care Act | 8 | | is repealed by an Act of Congress or is invalidated by a | 9 | | decision of the U.S. Supreme Court.
| 10 | | (Source: P.A. 99-407, eff. (see Section 99 of P.A. 99-407 for | 11 | | its effective date).) | 12 | | Section 95. No acceleration or delay. Where this Act makes | 13 | | changes in a statute that is represented in this Act by text | 14 | | that is not yet or no longer in effect (for example, a Section | 15 | | represented by multiple versions), the use of that text does | 16 | | not accelerate or delay the taking effect of (i) the changes | 17 | | made by this Act or (ii) provisions derived from any other | 18 | | Public Act. | 19 | | Section 99. Effective date. This Act takes effect on July | 20 | | 1, 2016.
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