Full Text of SB1254 99th General Assembly
SB1254sam001 99TH GENERAL ASSEMBLY | Sen. Antonio Muñoz Filed: 4/28/2015
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| 1 | | AMENDMENT TO SENATE BILL 1254
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1254 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. As used in this Section, "Affordable Care Act" | 5 | | is the collective term for the Patient Protection and | 6 | | Affordable Care Act (Pub. L. 111-148) and the Health Care and | 7 | | Education Reconciliation Act of 2010 (Pub. L. 111-152). | 8 | | The Affordable Care Act has increased the number of | 9 | | individuals utilizing health care services and
enrolling in the | 10 | | programs administered by the Department of Healthcare and | 11 | | Family Services. The needs
of these individuals and the | 12 | | budgetary constraints of the State of Illinois dictate that | 13 | | payment for these
services shall be consistent with efficiency, | 14 | | economy, and quality of care and based on principles that
| 15 | | maintain access to care and avoid and reduce fraud. One manner | 16 | | by which these objectives shall be
achieved is through the | 17 | | utilization of a uniform certification of medical necessity for |
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| 1 | | non-emergency
ambulance transportation. This certification | 2 | | will help ensure that payment is based on the appropriate
| 3 | | medical level of non-emergency transportation and, thus, will | 4 | | help establish medical necessity and
prevent overutilization | 5 | | of services and unnecessary transportation. Another manner by | 6 | | which these
objectives shall be achieved is through the | 7 | | transition from the Department's current payment
methodology | 8 | | based on the county of the primary office location of the | 9 | | enrolled transportation provider
to a payment methodology | 10 | | based on the zip code of an individual's point of pick-up by | 11 | | the transportation provider. Yet another manner
by which these | 12 | | objectives shall be achieved is to limit the number of | 13 | | enrollment applications and
agreements required by a | 14 | | transportation provider. Numerous enrollment applications and | 15 | | agreements
for a transportation provider increases the risk of | 16 | | fraud and abuse by, among other things, enabling a
provider to | 17 | | hide behind multiple agreements in order to continue provider | 18 | | enrollment and
reimbursement. | 19 | | Section 5. The Nursing Home Care Act is amended by changing | 20 | | Section 2-217 as follows: | 21 | | (210 ILCS 45/2-217) | 22 | | Sec. 2-217. Order for transportation of resident by | 23 | | ambulance. | 24 | | (a) If a facility orders transportation of a resident of |
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| 1 | | the facility by ambulance, the facility must maintain a written | 2 | | record that shows (i) the name of the person who placed the | 3 | | order for that transportation and (ii) the medical reason for | 4 | | that transportation. The facility must maintain the record for | 5 | | a period of at least 3 years after the date of the order for | 6 | | transportation by ambulance. | 7 | | (b) Beginning for dates of service no later than 90 days | 8 | | after the effective date of this amendatory Act of the 99th | 9 | | General Assembly, a facility shall utilize the uniform | 10 | | certification of medical necessity for non-emergency ambulance | 11 | | transportation pursuant to Section 5-4.2 of the Illinois Public | 12 | | Aid Code for all non-emergency ambulance transportation, | 13 | | regardless of whether the payer for the transport is a | 14 | | governmental payer or a non-governmental payer and regardless | 15 | | of the type of health care program or insurance the individual | 16 | | participates in. The uniform certification is not required | 17 | | prior to transport if it is reasonable to believe a delay in | 18 | | transport can be expected to negatively affect the efficient | 19 | | transportation of residents from the facility as determined by | 20 | | the facility. | 21 | | (c) It is the intention of the General Assembly that the | 22 | | State action exemption to the application of federal and State | 23 | | antitrust statutes be fully available to the Department, its | 24 | | vendors, agents, designees, and facilities, and all employees, | 25 | | officers, subsidiaries, and designees thereof, to the extent | 26 | | the activities facilitate the efficient transportation of |
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| 1 | | residents and provide a streamlined uniform medical necessity | 2 | | certification process. | 3 | | The State action exemption shall be liberally construed in | 4 | | favor of the Department, its vendors, agents, designees, and | 5 | | facilities, and all employees, officers, subsidiaries, and | 6 | | designees thereof, and such exemption shall be available | 7 | | notwithstanding that the action constitutes an irregular | 8 | | exercise of constitutional or statutory powers. | 9 | | It is the policy of this State that the following powers | 10 | | may be exercised by the Department, its vendors, agents, | 11 | | designees, and facilities, and all employees, officers, | 12 | | subsidiaries, and designees thereof, notwithstanding the | 13 | | effects on competition and notwithstanding any displacement of | 14 | | competition: | 15 | | (1) all powers that are within traditional areas of the | 16 | | Department's activity but that are authorized by this | 17 | | amendatory Act of the 99th General Assembly to be | 18 | | implemented by the Department's vendors, agents, | 19 | | designees, and facilities, and all employees, officers, | 20 | | subsidiaries, and designees thereof; | 21 | | (2) all powers granted, either expressly or by | 22 | | necessary implication under this amendatory Act of the 99th | 23 | | General Assembly, or any administrative rules, policies, | 24 | | or procedures that implement this amendatory Act of the | 25 | | 99th General Assembly; or | 26 | | (3) all powers that are the inherent, logical, or |
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| 1 | | ordinary results of the powers granted by this amendatory | 2 | | Act of the 99th General Assembly or any administrative | 3 | | rules, policies, or procedures that implement this | 4 | | amendatory Act of the 99th General Assembly.
| 5 | | In order to ensure that the non-Department individuals or | 6 | | entities identified in this subsection promote State policy and | 7 | | not individual interest, the Department shall actively | 8 | | supervise their activities, including, but not limited to, | 9 | | their decisions. The Department's active supervision shall | 10 | | include, but not be limited to, a review of the substance of | 11 | | any activities or decisions and the power to veto or modify | 12 | | particular activities or decisions to ensure they accord with | 13 | | State policy. The mere potential for State supervision shall | 14 | | not be a sufficient substitute for an actual decision by the | 15 | | Department. Department supervisors shall not be active market | 16 | | participants. | 17 | | (Source: P.A. 94-1063, eff. 1-31-07 .) | 18 | | Section 10. The Hospital Licensing Act is amended by | 19 | | changing Section 6.22 as follows: | 20 | | (210 ILCS 85/6.22) | 21 | | Sec. 6.22. Arrangement for transportation of patient by | 22 | | ambulance.
| 23 | | (a) In this Section: | 24 | | "Ambulance service provider" means a Vehicle Service |
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| 1 | | Provider as defined in the Emergency Medical Services (EMS) | 2 | | Systems Act who provides non-emergency transportation | 3 | | services by ambulance. | 4 | | "Patient" means a person who is transported by an | 5 | | ambulance service provider.
| 6 | | (b) Beginning for dates of service no later than 90 days | 7 | | after the effective date of this amendatory act of the 99th | 8 | | General Assembly, a hospital shall utilize the uniform | 9 | | certification of medical necessity for non-emergency ambulance | 10 | | transportation pursuant to Section 5-4.2 of the Illinois Public | 11 | | Aid Code for all non-emergency ambulance transports, | 12 | | regardless of whether the payer for the transport is a | 13 | | governmental payer or a non-governmental payer and regardless | 14 | | of the type of health care program or insurance the patient | 15 | | participates in. The uniform certification is not required | 16 | | prior to transport if it is reasonable to believe a delay in | 17 | | transport can be expected to negatively affect the efficient | 18 | | flow of patients from the hospital as determined by the | 19 | | hospital. If a hospital arranges for transportation of a | 20 | | patient of the hospital by ambulance, the hospital must provide | 21 | | the ambulance service provider, prior to transport, a Physician | 22 | | Certification Statement formatted and completed in compliance | 23 | | with federal regulations or an equivalent form developed by the | 24 | | hospital. | 25 | | (b-5) It is the intention of the General Assembly that the | 26 | | State action exemption to the application of federal and State |
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| 1 | | antitrust statutes be fully available to the Department, its | 2 | | vendors, agents, designees, and hospitals, and all employees, | 3 | | officers, subsidiaries, and designees thereof, to the extent | 4 | | the activities facilitate the efficient transportation of | 5 | | patients and provide a streamlined uniform medical necessity | 6 | | certification process. | 7 | | The State action exemption shall be liberally construed in | 8 | | favor of the Department, its vendors, agents, designees, and | 9 | | hospitals, and all employees, officers, subsidiaries, and | 10 | | designees thereof, and such exemption shall be available | 11 | | notwithstanding that the action constitutes an irregular | 12 | | exercise of constitutional or statutory powers. | 13 | | It is the policy of this State that the following powers | 14 | | may be exercised by the Department, its vendors, agents, | 15 | | designees, and hospitals, and all employees, officers, | 16 | | subsidiaries, and designees thereof, notwithstanding the | 17 | | effects on competition and notwithstanding any displacement of | 18 | | competition: | 19 | | (1) all powers that are within traditional areas of the | 20 | | Department's activity but that are authorized by this | 21 | | amendatory Act of the 99th General Assembly to be | 22 | | implemented by the Department's vendors, agents, | 23 | | designees, and hospitals, and all employees, officers, | 24 | | subsidiaries, and designees thereof; | 25 | | (2) all powers granted, either expressly or by | 26 | | necessary implication by this amendatory Act of the 99th |
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| 1 | | General Assembly, or any administrative rules, policies, | 2 | | or procedures that implement this amendatory Act of the | 3 | | 99th General Assembly; or | 4 | | (3) all powers that are the inherent, logical, or | 5 | | ordinary results of the powers granted by this amendatory | 6 | | Act of the 99th General Assembly or any administrative | 7 | | rules, policies, or procedures that implement this | 8 | | amendatory Act of the 99th General Assembly. | 9 | | In order to ensure that the non-Department individuals or | 10 | | entities identified in this subsection promote State policy and | 11 | | not individual interest, the Department shall actively | 12 | | supervise the activities, including, but not limited to, the | 13 | | decisions, of the non-Department individual or entity that are | 14 | | authorized and made pursuant to this amendatory Act of the 99th | 15 | | General Assembly. The Department's active supervision shall | 16 | | include, but not be limited to, a review of the substance of | 17 | | any activities or decisions and the power to veto or modify | 18 | | particular activities or decisions to ensure they accord with | 19 | | State policy. The mere potential for State supervision shall | 20 | | not be a sufficient substitute for an actual decision by the | 21 | | Department. Department supervisors shall not be active market | 22 | | participants. | 23 | | The Physician Certification Statement or equivalent form | 24 | | is not required prior to transport if a delay in transport can | 25 | | be expected to negatively affect the patient outcome. | 26 | | (c) If a hospital is unable to provide a uniform |
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| 1 | | certification of medical necessity for non-emergency ambulance | 2 | | transportation a Physician Certification Statement or | 3 | | equivalent form , then the hospital shall provide to the patient | 4 | | a written notice and a verbal explanation of the written | 5 | | notice, which notice must meet all of the following | 6 | | requirements:
| 7 | | (1) The following caption must appear at the beginning | 8 | | of the notice in at least 14-point type: Notice to Patient | 9 | | Regarding Non-Emergency Ambulance Services. | 10 | | (2) The notice must contain each of the following | 11 | | statements in at least 14-point type: | 12 | | (A) The purpose of this notice is to help you make | 13 | | an informed choice about whether you want to be | 14 | | transported by ambulance because your medical | 15 | | condition does not meet medical necessity for | 16 | | transportation by an ambulance. | 17 | | (B) Your insurance may not cover the charges for | 18 | | ambulance transportation. | 19 | | (C) You may be responsible for the cost of | 20 | | ambulance transportation. | 21 | | (D) The estimated cost of ambulance transportation | 22 | | is $(amount). | 23 | | (3) The notice must be signed by the patient or by the | 24 | | patient's authorized representative. A copy shall be given | 25 | | to the patient and the hospital shall retain a copy. | 26 | | (d) The notice set forth in subsection (c) of this Section |
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| 1 | | shall not be required if a delay in transport can be expected | 2 | | to negatively affect the patient outcome. | 3 | | (e) If a patient is physically or mentally unable to sign | 4 | | the notice described in subsection (c) of this Section and no | 5 | | authorized representative of the patient is available to sign | 6 | | the notice on the patient's behalf, the hospital must be able | 7 | | to provide documentation of the patient's inability to sign the | 8 | | notice and the unavailability of an authorized representative. | 9 | | In any case described in this subsection (e), the hospital | 10 | | shall be considered to have met the requirements of subsection | 11 | | (c) of this Section.
| 12 | | (Source: P.A. 94-1063, eff. 1-31-07 .) | 13 | | Section 15. The Illinois Public Aid Code is amended by | 14 | | changing Sections 5-4.2 and 5-5 as follows:
| 15 | | (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
| 16 | | Sec. 5-4.2. Ground ambulance Ambulance services , medi-car | 17 | | services, and service car services payments. | 18 | | (a) For purposes of this Section, the following terms have | 19 | | the following meanings: | 20 | | "Department" means the Illinois Department of Healthcare | 21 | | and Family Services. | 22 | | "Ground ambulance services" means medical transportation | 23 | | services that are described as ground ambulance services by the | 24 | | federal Centers for Medicare and Medicaid Services in 42 CFR |
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| 1 | | 414.605 and any subsequent amendments, policies, and | 2 | | guidelines thereto and that are provided in a vehicle that is | 3 | | (i) licensed as an ambulance by the Department of Public Health | 4 | | pursuant to the Emergency Medical Services (EMS) Systems Act or | 5 | | (ii) licensed as an ambulance in another state in accordance | 6 | | with the laws of that state. | 7 | | "Ground ambulance services provider" means a vehicle | 8 | | service provider as described in the Emergency Medical Services | 9 | | (EMS) Systems Act that provides emergency ground ambulance | 10 | | services or non-emergency ground ambulance services, or both. | 11 | | "Ground ambulance services provider" includes a vehicle | 12 | | service provider that is licensed in another state pursuant to | 13 | | the laws of that other state. | 14 | | "Medi-car services provider" means a provider of medi-car | 15 | | services. | 16 | | "Medi-car services" means medical transportation services | 17 | | provided by means of vehicles licensed by the Secretary of | 18 | | State as medi-car vehicles and, for organizations | 19 | | headquartered outside Illinois, by means of vehicles | 20 | | authorized to do business as medi-car vehicles pursuant to the | 21 | | laws of the state in which the organization is headquartered. | 22 | | "Payment principles of Medicare" means the accepted | 23 | | methods propounded by the federal Centers for Medicare and | 24 | | Medicaid Services and used to determine the administration of | 25 | | the payment system for ground ambulance services providers and | 26 | | suppliers under Title XVIII of the Social Security Act. These |
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| 1 | | principles are outlined in the United States Code and the Code | 2 | | of Federal Regulations and in the procedures, policies, | 3 | | guidelines, and coding systems of the federal Centers for | 4 | | Medicare and Medicaid services, including, but not limited to, | 5 | | the CMS Online Manual System, the Medicare Benefit Policy | 6 | | Manual, the Medicare Claims Processing Manual, the Health Care | 7 | | Common Procedure Coding System (HCPCS), and the ambulance | 8 | | condition coding system. | 9 | | "Service car services" means transportation services | 10 | | provided by means of a service
car licensed as a livery car by | 11 | | the Secretary of State and, where applicable, by local | 12 | | regulatory agencies or, for organizations headquartered | 13 | | outside of Illinois, by means of vehicles authorized to do | 14 | | business as service cars pursuant to the laws of the state in | 15 | | which the organization is headquartered. | 16 | | "Emergency and urgently needed services" has the meaning | 17 | | ascribed to that term in 42 CFR 422.113 and any subsequent | 18 | | amendments, policies, and guidelines thereto. | 19 | | (b) Unless otherwise indicated in this Section, the | 20 | | practices of the Department concerning payments for ground | 21 | | ambulance services provided to recipients covered by a medical | 22 | | assistance program administered by the Department shall be | 23 | | consistent with the payment principles of Medicare. | 24 | | (c) For ground ambulance services and medi-car services | 25 | | provided to recipients covered by a medical assistance program | 26 | | administered by the Department, payment shall be based upon the |
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| 1 | | zip code of the point of pick-up of the recipient by the ground | 2 | | ambulance services provider or medi-car services provider. The | 3 | | payment rate of each zip code shall equal the rate of the | 4 | | county in the Department-issued fee schedule where the zip code | 5 | | is located. For zip codes that exist in multiple counties, | 6 | | payment shall equal the rate in the Department-issued fee | 7 | | schedule of the county which includes the majority of the land | 8 | | area that the zip code covers. The payment methodology based on | 9 | | the zip code point of pick-up, as described in this subsection, | 10 | | shall be established by rule and shall be effective no later | 11 | | than January 1, 2016 in order to give the Department sufficient | 12 | | time to transition from its current payment methodology which | 13 | | is based upon the county of the primary office address listed | 14 | | in the transportation provider's enrollment application. | 15 | | (c-5) Due to the unique mobile nature of ambulance and | 16 | | medi-car services, ground ambulance services providers and | 17 | | medi-car services providers are required to only submit | 18 | | enrollment applications for the primary office location where | 19 | | the provider's business is headquartered. Nothing in this | 20 | | Section shall be construed or applied either retroactively or | 21 | | prospectively to require ground ambulance services providers | 22 | | and medi-car services providers to have more than one | 23 | | enrollment application and Medicaid provider number. The | 24 | | Department shall implement this subsection by rule. | 25 | | (d) Payment for mileage shall be per loaded mile with no | 26 | | loaded mileage included in the base rate. If a natural |
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| 1 | | disaster, weather, road repairs, traffic congestion, or other | 2 | | conditions necessitate a route other than the most direct | 3 | | route, payment shall be based upon the actual distance | 4 | | traveled. When a ground ambulance services provider provides | 5 | | transport, no reduction in the mileage payment shall be made | 6 | | based upon the fact that a closer facility may have been | 7 | | available, so long as the ground ambulance services provider | 8 | | provided transport to the recipient's facility of choice or | 9 | | another appropriate facility described within the scope of the | 10 | | Emergency Medical Services (EMS) Systems Act or associated | 11 | | rules or the policies and procedures of the EMS System of which | 12 | | the provider is a member or, in the case of a ground ambulance | 13 | | services provider licensed by another state, according to the | 14 | | laws, rules, policies, or procedures of the state in which the | 15 | | provider is licensed. | 16 | | (d-5) The Department shall provide payment for emergency | 17 | | and urgently needed ground ambulance services according to the | 18 | | requirements provided in this Section when those services are | 19 | | emergency and urgently needed services. Such services may, but | 20 | | shall not be required to, be provided pursuant to a request | 21 | | made through a 9-1-1 or equivalent emergency telephone number | 22 | | for evaluation, treatment, and transport of or on behalf of an | 23 | | individual with a condition of such a nature that a prudent | 24 | | layperson would have reasonably expected that a delay in | 25 | | seeking immediate medical attention would have been hazardous | 26 | | to life or health. This standard is deemed to be met if there |
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| 1 | | is an emergency or urgent medical condition manifesting itself | 2 | | by acute symptoms of sufficient severity, including, but not | 3 | | limited to, severe pain, such that a prudent layperson who | 4 | | possesses an average knowledge of health and medicine can | 5 | | reasonably expect that the absence of immediate medical | 6 | | attention could result in placing the health of the individual | 7 | | or, with respect to a pregnant woman, the health of the woman | 8 | | or her unborn child, in serious jeopardy, or cause serious | 9 | | impairment to bodily functions, or cause serious dysfunction of | 10 | | any bodily organ or part. | 11 | | (a) For
ambulance
services provided to a recipient of aid | 12 | | under this Article on or after
January 1, 1993, the Illinois | 13 | | Department shall reimburse ambulance service
providers at | 14 | | rates calculated in accordance with this Section. It is the | 15 | | intent
of the General Assembly to provide adequate | 16 | | reimbursement for ambulance
services so as to ensure adequate | 17 | | access to services for recipients of aid
under this Article and | 18 | | to provide appropriate incentives to ambulance service
| 19 | | providers to provide services in an efficient and | 20 | | cost-effective manner. Thus,
it is the intent of the General | 21 | | Assembly that the Illinois Department implement
a | 22 | | reimbursement system for ambulance services that, to the extent | 23 | | practicable
and subject to the availability of funds | 24 | | appropriated by the General Assembly
for this purpose, is | 25 | | consistent with the payment principles of Medicare. To
ensure | 26 | | uniformity between the payment principles of Medicare and |
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| 1 | | Medicaid, the
Illinois Department shall follow, to the extent | 2 | | necessary and practicable and
subject to the availability of | 3 | | funds appropriated by the General Assembly for
this purpose, | 4 | | the statutes, laws, regulations, policies, procedures,
| 5 | | principles, definitions, guidelines, and manuals used to | 6 | | determine the amounts
paid to ambulance service providers under | 7 | | Title XVIII of the Social Security
Act (Medicare).
| 8 | | (b) For ambulance services provided to a recipient of aid | 9 | | under this Article
on or after January 1, 1996, the Illinois | 10 | | Department shall reimburse ambulance
service providers based | 11 | | upon the actual distance traveled if a natural
disaster, | 12 | | weather conditions, road repairs, or traffic congestion | 13 | | necessitates
the use of a
route other than the most direct | 14 | | route.
| 15 | | (c) For purposes of this Section, "ambulance services" | 16 | | includes medical
transportation services provided by means of | 17 | | an ambulance, medi-car, service
car, or
taxi.
| 18 | | (c-1) For purposes of this Section, "ground ambulance | 19 | | service" means medical transportation services that are | 20 | | described as ground ambulance services by the Centers for | 21 | | Medicare and Medicaid Services and provided in a vehicle that | 22 | | is licensed as an ambulance by the Illinois Department of | 23 | | Public Health pursuant to the Emergency Medical Services (EMS) | 24 | | Systems Act. | 25 | | (c-2) For purposes of this Section, "ground ambulance | 26 | | service provider" means a vehicle service provider as described |
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| 1 | | in the Emergency Medical Services (EMS) Systems Act that | 2 | | operates licensed ambulances for the purpose of providing | 3 | | emergency ambulance services, or non-emergency ambulance | 4 | | services, or both. For purposes of this Section, this includes | 5 | | both ambulance providers and ambulance suppliers as described | 6 | | by the Centers for Medicare and Medicaid Services. | 7 | | (d) This Section does not prohibit separate billing by | 8 | | ambulance service
providers for oxygen furnished while | 9 | | providing advanced life support
services.
| 10 | | (e) Beginning with services rendered on or after July 1, | 11 | | 2008, all providers of non-emergency medi-car and service car | 12 | | transportation must certify that the driver and employee | 13 | | attendant, as applicable, have completed a safety program | 14 | | approved by the Department to protect both the patient and the | 15 | | driver, prior to transporting a patient.
The provider must | 16 | | maintain this certification in its records. The provider shall | 17 | | produce such documentation upon demand by the Department or its | 18 | | representative. Failure to produce documentation of such | 19 | | training shall result in recovery of any payments made by the | 20 | | Department for services rendered by a non-certified driver or | 21 | | employee attendant. Medi-car and service car providers must | 22 | | maintain legible documentation in their records of the driver | 23 | | and, as applicable, employee attendant that actually | 24 | | transported the patient. Providers must recertify all drivers | 25 | | and employee attendants every 3 years.
| 26 | | Notwithstanding the requirements above, any public |
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| 1 | | transportation provider of medi-car and service car | 2 | | transportation that receives federal funding under 49 U.S.C. | 3 | | 5307 and 5311 need not certify its drivers and employee | 4 | | attendants under this Section, since safety training is already | 5 | | federally mandated.
| 6 | | (f) With respect to any policy or program administered by | 7 | | the Department or its agent regarding approval of non-emergency | 8 | | medical transportation by ground ambulance services service | 9 | | providers and, beginning for dates of service no later than 90 | 10 | | days after the effective date of this amendatory Act of the | 11 | | 99th General Assembly, by medi-car services providers , | 12 | | including, but not limited to, the Non-Emergency | 13 | | Transportation Services Prior Approval Program (NETSPAP), the | 14 | | Department shall establish by rule a process by which ground | 15 | | ambulance services service providers and medi-car services | 16 | | providers of non-emergency medical transportation may appeal | 17 | | any decision by the Department or its agent for which no denial | 18 | | was received prior to the time of transport that either (i) | 19 | | denies a request for approval for payment of non-emergency | 20 | | transportation by means of ground ambulance services or | 21 | | medi-car services service or (ii) grants a request for approval | 22 | | of non-emergency transportation by means of ground ambulance | 23 | | services or medi-car services service at a level of service | 24 | | that entitles the ground ambulance services service provider or | 25 | | medi-car services provider to a lower level of compensation | 26 | | from the Department than the ground ambulance services service |
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| 1 | | provider or medi-car services provider would have received as | 2 | | compensation for the level of service requested. The rule shall | 3 | | be filed by December 15, 2012 and shall provide that , for any | 4 | | decision rendered by the Department or its agent on or after | 5 | | the date the rule takes effect, the ground ambulance services | 6 | | service provider and medi-car services provider shall have 60 | 7 | | days from the date the decision is received to file an appeal. | 8 | | The rule established by the Department shall be , insofar as is | 9 | | practical, consistent with the Illinois Administrative | 10 | | Procedure Act. The decision of the Director Director's decision | 11 | | on an appeal under this Section shall be a final administrative | 12 | | decision subject to review under the Administrative Review Law. | 13 | | (f-5) Beginning 90 days after July 20, 2012 (the effective | 14 | | date of Public Act 97-842) and, for medi-car services, | 15 | | beginning 90 days after the effective date of this amendatory | 16 | | Act of the 99th General Assembly , (i) no denial of a request | 17 | | for approval for payment of non-emergency transportation by | 18 | | means of ground ambulance services service or medi-car | 19 | | services , and (ii) no approval of non-emergency transportation | 20 | | by means of ground ambulance services or medi-car services | 21 | | service at a level of service that entitles the ground | 22 | | ambulance service provider to a lower level of compensation | 23 | | from the Department than would have been received at the level | 24 | | of service submitted by the ground ambulance services service | 25 | | provider or medi-car services provider , may be issued by the | 26 | | Department or its agent unless the Department has submitted the |
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| 1 | | criteria for determining the appropriateness of the transport | 2 | | for first notice publication in the Illinois Register pursuant | 3 | | to Section 5-40 of the Illinois Administrative Procedure Act. | 4 | | (g) (Blank). Whenever a patient covered by a medical | 5 | | assistance program under this Code or by another medical | 6 | | program administered by the Department is being discharged from | 7 | | a facility, a physician discharge order as described in this | 8 | | Section shall be required for each patient whose discharge | 9 | | requires medically supervised ground ambulance services. | 10 | | Facilities shall develop procedures for a physician with | 11 | | medical staff privileges to provide a written and signed | 12 | | physician discharge order. The physician discharge order shall | 13 | | specify the level of ground ambulance services needed and | 14 | | complete a medical certification establishing the criteria for | 15 | | approval of non-emergency ambulance transportation, as | 16 | | published by the Department of Healthcare and Family Services, | 17 | | that is met by the patient. This order and the medical | 18 | | certification shall be completed prior to ordering an ambulance | 19 | | service and prior to patient discharge. | 20 | | Pursuant to subsection (E) of Section 12-4.25 of this Code, | 21 | | the Department is entitled to recover overpayments paid to a | 22 | | provider or vendor, including, but not limited to, from the | 23 | | discharging physician, the discharging facility, and the | 24 | | ground ambulance service provider, in instances where a | 25 | | non-emergency ground ambulance service is rendered as the | 26 | | result of improper or false certification. |
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| 1 | | (h) On and after July 1, 2012, the Department shall reduce | 2 | | any rate of reimbursement for services or other payments or | 3 | | alter any methodologies authorized by this Code to reduce any | 4 | | rate of reimbursement for services or other payments in | 5 | | accordance with Section 5-5e. | 6 | | (h-5) Beginning for dates of service no later than 90 days | 7 | | after the effective date of this amendatory Act of the 99th | 8 | | General Assembly, whenever a recipient covered by a medical | 9 | | assistance program administered by the Department or by the | 10 | | federal Medicare program is being transported on a | 11 | | non-emergency basis from a hospital, as described in the | 12 | | Hospital Licensing Act or the University of Illinois Hospital | 13 | | Act, or from a nursing facility, as described in the Nursing | 14 | | Home Care Act, a uniform certification of medical necessity for | 15 | | non-emergency ambulance transportation, as described in this | 16 | | subsection, shall be required for each recipient whose | 17 | | transportation requires medically supervised ground ambulance | 18 | | services. Facilities shall develop procedures for a physician | 19 | | with medical staff privileges or appropriate designee to | 20 | | provide a written and signed uniform certification of medical | 21 | | necessity for non-emergency ambulance transportation. The | 22 | | uniform certification of medical necessity for non-emergency | 23 | | ambulance transportation shall be established by rule and shall | 24 | | specify the level of ground ambulance services needed and shall | 25 | | establish the medical necessity for the transport in accordance | 26 | | with Medicare requirements set forth in 42 CFR 410.40 and any |
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| 1 | | subsequent amendments, policies, procedures, and guidelines | 2 | | thereto. Pursuant to subsection (E) of Section 12-4.25 of this | 3 | | Code, the Department is entitled to recover overpayments paid | 4 | | to a provider, including, but not limited to, from the | 5 | | physician, hospital, or nursing facility ordering the | 6 | | transportation, or the ground ambulance services provider | 7 | | providing the transportation, in instances where a | 8 | | non-emergency ground ambulance service is rendered as the | 9 | | result of an improper or false certification. | 10 | | (h-6) It is the intention of the General Assembly that the | 11 | | State action exemption to the application of federal and State | 12 | | antitrust statutes be fully available to the Department, its | 13 | | vendors, agents, designees, and enrolled providers, and all | 14 | | employees, officers, subsidiaries, and designees thereof, to | 15 | | the extent the activities relate to the mileage criteria and | 16 | | methodology, emergency and urgently needed methodology and | 17 | | criteria, appeals process including post authorization for | 18 | | non-prescheduled, non-emergency transportation, and uniform | 19 | | certification of medical necessity for non-emergency ambulance | 20 | | transportation. | 21 | | The State action exemption shall be liberally construed in | 22 | | favor of the Department, its vendors, agents, designees, and | 23 | | enrolled providers, and all employees, officers, subsidiaries, | 24 | | and designees thereof, and such exemption shall be available | 25 | | notwithstanding that the action constitutes an irregular | 26 | | exercise of constitutional or statutory powers. |
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| 1 | | It is the policy of this State that the following powers | 2 | | may be exercised by the Department, its vendors, agents, | 3 | | designees, and enrolled providers, and all employees, | 4 | | officers, subsidiaries, and designees thereof, notwithstanding | 5 | | the effects on competition and notwithstanding any | 6 | | displacement of competition: | 7 | | (1) all powers that are within traditional areas of the | 8 | | Department's activity but that are to be implemented by the | 9 | | Department's vendors, agents, designees, and enrolled | 10 | | providers, and all employees, officers, subsidiaries, and | 11 | | designees thereof, pursuant to this amendatory Act of the
| 12 | | 99th General Assembly only as the powers relate to mileage | 13 | | criteria and
methodology, emergency and urgently needed | 14 | | methodology and criteria, appeals
processes including post | 15 | | authorization for non-prescheduled, non-emergency
| 16 | | transportation, and uniform certification of medical | 17 | | necessity for non-emergency
ambulance transportation. | 18 | | (2) all powers granted, either expressly or by | 19 | | necessary implication, by this amendatory act of the 99th
| 20 | | General Assembly or any rules, policies, or procedures that | 21 | | implement this amendatory act of the 99th
General Assembly | 22 | | only if such powers, rules, policies, or procedures relate | 23 | | to: mileage criteria and methodology, emergency and | 24 | | urgently needed methodology and criteria, appeals | 25 | | processes including post authorization for | 26 | | non-prescheduled, non-emergency transportation, and |
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| 1 | | uniform certification of medical necessity for | 2 | | non-emergency ambulance transportation; or | 3 | | (3) all powers that are
the inherent, logical, or | 4 | | ordinary results of the powers granted by this
amendatory | 5 | | Act of the 99th General Assembly or any rules, policies, or
| 6 | | procedures that implement this amendatory Act of the 99th | 7 | | General Assembly
only if such powers, rules, policies, or | 8 | | procedures relate to:
mileage criteria and methodology, | 9 | | emergency and urgently needed methodology
and criteria, | 10 | | appeals processes including post authorization for | 11 | | non-prescheduled,
non-emergency transportation, and | 12 | | uniform certification of
medical necessity for | 13 | | non-emergency ambulance transportation. | 14 | | In order to ensure that the non-Department individuals or | 15 | | entities identified in this subsection promote State policy and | 16 | | not individual interest, the Department shall actively | 17 | | supervise their activities and their decisions. The | 18 | | Department's active supervision shall include, but not be | 19 | | limited to, a review of the substance of any activities or | 20 | | decisions and the power to veto or modify particular activities | 21 | | or decisions to ensure they accord with State policy. The mere | 22 | | potential for State supervision shall not be a sufficient | 23 | | substitute for an actual decision by the Department. Department | 24 | | supervisors shall not be active market participants. | 25 | | (i) Beginning no later than July 1, 2015, the Department | 26 | | shall establish a technical advisory group to collaborate with |
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| 1 | | and assist in the development of the regulations, policies, or | 2 | | procedures necessary to implement this amendatory Act of the | 3 | | 99th General Assembly. This technical advisory group shall | 4 | | include a statewide association representing municipal, | 5 | | not-for-profit and private providers as a diverse, statewide | 6 | | representation of the ambulance community, a statewide | 7 | | association representing emergency physicians, a statewide | 8 | | association representing hospitals, and a statewide | 9 | | association representing nursing facilities. The Department | 10 | | shall share information with and provide technical assistance | 11 | | to the non-Departmental members of the group. The Department | 12 | | shall share all drafts of administrative rules, policies, and | 13 | | procedures developed pursuant to this amendatory Act of the | 14 | | 99th General Assembly with the technical advisory group at | 15 | | least 90 days prior to the implementation date. | 16 | | (Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12; | 17 | | 97-842, eff. 7-20-12; 98-463, eff. 8-16-13.)
| 18 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 19 | | Sec. 5-5. Medical services. The Illinois Department, by | 20 | | rule, shall
determine the quantity and quality of and the rate | 21 | | of reimbursement for the
medical assistance for which
payment | 22 | | will be authorized, and the medical services to be provided,
| 23 | | which may include all or part of the following: (1) inpatient | 24 | | hospital
services; (2) outpatient hospital services; (3) other | 25 | | laboratory and
X-ray services; (4) skilled nursing home |
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| 1 | | services; (5) physicians'
services whether furnished in the | 2 | | office, the patient's home, a
hospital, a skilled nursing home, | 3 | | or elsewhere; (6) medical care, or any
other type of remedial | 4 | | care furnished by licensed practitioners; (7)
home health care | 5 | | services; (8) private duty nursing service; (9) clinic
| 6 | | services; (10) dental services, including prevention and | 7 | | treatment of periodontal disease and dental caries disease for | 8 | | pregnant women, provided by an individual licensed to practice | 9 | | dentistry or dental surgery; for purposes of this item (10), | 10 | | "dental services" means diagnostic, preventive, or corrective | 11 | | procedures provided by or under the supervision of a dentist in | 12 | | the practice of his or her profession; (11) physical therapy | 13 | | and related
services; (12) prescribed drugs, dentures, and | 14 | | prosthetic devices; and
eyeglasses prescribed by a physician | 15 | | skilled in the diseases of the eye,
or by an optometrist, | 16 | | whichever the person may select; (13) other
diagnostic, | 17 | | screening, preventive, and rehabilitative services, including | 18 | | to ensure that the individual's need for intervention or | 19 | | treatment of mental disorders or substance use disorders or | 20 | | co-occurring mental health and substance use disorders is | 21 | | determined using a uniform screening, assessment, and | 22 | | evaluation process inclusive of criteria, for children and | 23 | | adults; for purposes of this item (13), a uniform screening, | 24 | | assessment, and evaluation process refers to a process that | 25 | | includes an appropriate evaluation and, as warranted, a | 26 | | referral; "uniform" does not mean the use of a singular |
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| 1 | | instrument, tool, or process that all must utilize; (14)
| 2 | | transportation and such other expenses as may be necessary | 3 | | pursuant to 5-4.2 of this Code ; (15) medical
treatment of | 4 | | sexual assault survivors, as defined in
Section 1a of the | 5 | | Sexual Assault Survivors Emergency Treatment Act, for
injuries | 6 | | sustained as a result of the sexual assault, including
| 7 | | examinations and laboratory tests to discover evidence which | 8 | | may be used in
criminal proceedings arising from the sexual | 9 | | assault; (16) the
diagnosis and treatment of sickle cell | 10 | | anemia; and (17)
any other medical care, and any other type of | 11 | | remedial care recognized
under the laws of this State, but not | 12 | | including abortions, or induced
miscarriages or premature | 13 | | births, unless, in the opinion of a physician,
such procedures | 14 | | are necessary for the preservation of the life of the
woman | 15 | | seeking such treatment, or except an induced premature birth
| 16 | | intended to produce a live viable child and such procedure is | 17 | | necessary
for the health of the mother or her unborn child. The | 18 | | Illinois Department,
by rule, shall prohibit any physician from | 19 | | providing medical assistance
to anyone eligible therefor under | 20 | | this Code where such physician has been
found guilty of | 21 | | performing an abortion procedure in a wilful and wanton
manner | 22 | | upon a woman who was not pregnant at the time such abortion
| 23 | | procedure was performed. The term "any other type of remedial | 24 | | care" shall
include nursing care and nursing home service for | 25 | | persons who rely on
treatment by spiritual means alone through | 26 | | prayer for healing.
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| 1 | | Notwithstanding any other provision of this Section, a | 2 | | comprehensive
tobacco use cessation program that includes | 3 | | purchasing prescription drugs or
prescription medical devices | 4 | | approved by the Food and Drug Administration shall
be covered | 5 | | under the medical assistance
program under this Article for | 6 | | persons who are otherwise eligible for
assistance under this | 7 | | Article.
| 8 | | Notwithstanding any other provision of this Code, the | 9 | | Illinois
Department may not require, as a condition of payment | 10 | | for any laboratory
test authorized under this Article, that a | 11 | | physician's handwritten signature
appear on the laboratory | 12 | | test order form. The Illinois Department may,
however, impose | 13 | | other appropriate requirements regarding laboratory test
order | 14 | | documentation.
| 15 | | Upon receipt of federal approval of an amendment to the | 16 | | Illinois Title XIX State Plan for this purpose, the Department | 17 | | shall authorize the Chicago Public Schools (CPS) to procure a | 18 | | vendor or vendors to manufacture eyeglasses for individuals | 19 | | enrolled in a school within the CPS system. CPS shall ensure | 20 | | that its vendor or vendors are enrolled as providers in the | 21 | | medical assistance program and in any capitated Medicaid | 22 | | managed care entity (MCE) serving individuals enrolled in a | 23 | | school within the CPS system. Under any contract procured under | 24 | | this provision, the vendor or vendors must serve only | 25 | | individuals enrolled in a school within the CPS system. Claims | 26 | | for services provided by CPS's vendor or vendors to recipients |
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| 1 | | of benefits in the medical assistance program under this Code, | 2 | | the Children's Health Insurance Program, or the Covering ALL | 3 | | KIDS Health Insurance Program shall be submitted to the | 4 | | Department or the MCE in which the individual is enrolled for | 5 | | payment and shall be reimbursed at the Department's or the | 6 | | MCE's established rates or rate methodologies for eyeglasses. | 7 | | On and after July 1, 2012, the Department of Healthcare and | 8 | | Family Services may provide the following services to
persons
| 9 | | eligible for assistance under this Article who are | 10 | | participating in
education, training or employment programs | 11 | | operated by the Department of Human
Services as successor to | 12 | | the Department of Public Aid:
| 13 | | (1) dental services provided by or under the | 14 | | supervision of a dentist; and
| 15 | | (2) eyeglasses prescribed by a physician skilled in the | 16 | | diseases of the
eye, or by an optometrist, whichever the | 17 | | person may select.
| 18 | | Notwithstanding any other provision of this Code and | 19 | | subject to federal approval, the Department may adopt rules to | 20 | | allow a dentist who is volunteering his or her service at no | 21 | | cost to render dental services through an enrolled | 22 | | not-for-profit health clinic without the dentist personally | 23 | | enrolling as a participating provider in the medical assistance | 24 | | program. A not-for-profit health clinic shall include a public | 25 | | health clinic or Federally Qualified Health Center or other | 26 | | enrolled provider, as determined by the Department, through |
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| 1 | | which dental services covered under this Section are performed. | 2 | | The Department shall establish a process for payment of claims | 3 | | for reimbursement for covered dental services rendered under | 4 | | this provision. | 5 | | The Illinois Department, by rule, may distinguish and | 6 | | classify the
medical services to be provided only in accordance | 7 | | with the classes of
persons designated in Section 5-2.
| 8 | | The Department of Healthcare and Family Services must | 9 | | provide coverage and reimbursement for amino acid-based | 10 | | elemental formulas, regardless of delivery method, for the | 11 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 12 | | short bowel syndrome when the prescribing physician has issued | 13 | | a written order stating that the amino acid-based elemental | 14 | | formula is medically necessary.
| 15 | | The Illinois Department shall authorize the provision of, | 16 | | and shall
authorize payment for, screening by low-dose | 17 | | mammography for the presence of
occult breast cancer for women | 18 | | 35 years of age or older who are eligible
for medical | 19 | | assistance under this Article, as follows: | 20 | | (A) A baseline
mammogram for women 35 to 39 years of | 21 | | age.
| 22 | | (B) An annual mammogram for women 40 years of age or | 23 | | older. | 24 | | (C) A mammogram at the age and intervals considered | 25 | | medically necessary by the woman's health care provider for | 26 | | 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 | | (D) 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 | | All screenings
shall
include a physical breast exam, | 9 | | instruction on self-examination and
information regarding the | 10 | | frequency of self-examination and its value as a
preventative | 11 | | tool. For purposes of this Section, "low-dose mammography" | 12 | | means
the x-ray examination of the breast using equipment | 13 | | dedicated specifically
for mammography, including the x-ray | 14 | | tube, filter, compression device,
and image receptor, with an | 15 | | average radiation exposure delivery
of less than one rad per | 16 | | breast for 2 views of an average size breast.
The term also | 17 | | includes digital mammography.
| 18 | | On and after January 1, 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. |
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| 1 | | Subject to federal approval, the Department shall | 2 | | establish a rate methodology for mammography at federally | 3 | | qualified health centers and other encounter-rate clinics. | 4 | | These clinics or centers may also collaborate with other | 5 | | hospital-based mammography facilities. | 6 | | The Department shall establish a methodology to remind | 7 | | women who are age-appropriate for screening mammography, but | 8 | | who have not received a mammogram within the previous 18 | 9 | | months, of the importance and benefit of screening mammography. | 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. An evaluation of the | 23 | | pilot program shall be carried out measuring health outcomes | 24 | | and cost of care for those served by the pilot program compared | 25 | | to similarly situated patients who are not served by the pilot | 26 | | program. |
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| 1 | | Any medical or health care provider shall immediately | 2 | | recommend, to
any pregnant woman who is being provided prenatal | 3 | | services and is suspected
of drug abuse or is addicted as | 4 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 5 | | Act, referral to a local substance abuse treatment provider
| 6 | | licensed by the Department of Human Services or to a licensed
| 7 | | hospital which provides substance abuse treatment services. | 8 | | The Department of Healthcare and Family Services
shall assure | 9 | | coverage for the cost of treatment of the drug abuse or
| 10 | | addiction for pregnant recipients in accordance with the | 11 | | Illinois Medicaid
Program in conjunction with the Department of | 12 | | Human Services.
| 13 | | All medical providers providing medical assistance to | 14 | | pregnant women
under this Code shall receive information from | 15 | | the Department on the
availability of services under the Drug | 16 | | Free Families with a Future or any
comparable program providing | 17 | | case management services for addicted women,
including | 18 | | information on appropriate referrals for other social services
| 19 | | that may be needed by addicted women in addition to treatment | 20 | | for addiction.
| 21 | | The Illinois Department, in cooperation with the | 22 | | Departments of Human
Services (as successor to the Department | 23 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 24 | | public awareness campaign, may
provide information concerning | 25 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 26 | | health care, and other pertinent programs directed at
reducing |
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| 1 | | the number of drug-affected infants born to recipients of | 2 | | medical
assistance.
| 3 | | Neither the Department of Healthcare and Family Services | 4 | | nor the Department of Human
Services shall sanction the | 5 | | recipient solely on the basis of
her substance abuse.
| 6 | | The Illinois Department shall establish such regulations | 7 | | governing
the dispensing of health services under this Article | 8 | | as it shall deem
appropriate. The Department
should
seek the | 9 | | advice of formal professional advisory committees appointed by
| 10 | | the Director of the Illinois Department for the purpose of | 11 | | providing regular
advice on policy and administrative matters, | 12 | | information dissemination and
educational activities for | 13 | | medical and health care providers, and
consistency in | 14 | | procedures to the Illinois Department.
| 15 | | The Illinois Department may develop and contract with | 16 | | Partnerships of
medical providers to arrange medical services | 17 | | for persons eligible under
Section 5-2 of this Code. | 18 | | Implementation of this Section may be by
demonstration projects | 19 | | in certain geographic areas. The Partnership shall
be | 20 | | represented by a sponsor organization. The Department, by rule, | 21 | | shall
develop qualifications for sponsors of Partnerships. | 22 | | Nothing in this
Section shall be construed to require that the | 23 | | sponsor organization be a
medical organization.
| 24 | | The sponsor must negotiate formal written contracts with | 25 | | medical
providers for physician services, inpatient and | 26 | | outpatient hospital care,
home health services, treatment for |
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| 1 | | alcoholism and substance abuse, and
other services determined | 2 | | necessary by the Illinois Department by rule for
delivery by | 3 | | Partnerships. Physician services must include prenatal and
| 4 | | obstetrical care. The Illinois Department shall reimburse | 5 | | medical services
delivered by Partnership providers to clients | 6 | | in target areas according to
provisions of this Article and the | 7 | | Illinois Health Finance Reform Act,
except that:
| 8 | | (1) Physicians participating in a Partnership and | 9 | | providing certain
services, which shall be determined by | 10 | | the Illinois Department, to persons
in areas covered by the | 11 | | Partnership may receive an additional surcharge
for such | 12 | | services.
| 13 | | (2) The Department may elect to consider and negotiate | 14 | | financial
incentives to encourage the development of | 15 | | Partnerships and the efficient
delivery of medical care.
| 16 | | (3) Persons receiving medical services through | 17 | | Partnerships may receive
medical and case management | 18 | | services above the level usually offered
through the | 19 | | medical assistance program.
| 20 | | Medical providers shall be required to meet certain | 21 | | qualifications to
participate in Partnerships to ensure the | 22 | | delivery of high quality medical
services. These | 23 | | qualifications shall be determined by rule of the Illinois
| 24 | | Department and may be higher than qualifications for | 25 | | participation in the
medical assistance program. Partnership | 26 | | sponsors may prescribe reasonable
additional qualifications |
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| 1 | | for participation by medical providers, only with
the prior | 2 | | written approval of the Illinois Department.
| 3 | | Nothing in this Section shall limit the free choice of | 4 | | practitioners,
hospitals, and other providers of medical | 5 | | services by clients.
In order to ensure patient freedom of | 6 | | choice, the Illinois Department shall
immediately promulgate | 7 | | all rules and take all other necessary actions so that
provided | 8 | | services may be accessed from therapeutically certified | 9 | | optometrists
to the full extent of the Illinois Optometric | 10 | | Practice Act of 1987 without
discriminating between service | 11 | | providers.
| 12 | | The Department shall apply for a waiver from the United | 13 | | States Health
Care Financing Administration to allow for the | 14 | | implementation of
Partnerships under this Section.
| 15 | | The Illinois Department shall require health care | 16 | | providers to maintain
records that document the medical care | 17 | | and services provided to recipients
of Medical Assistance under | 18 | | this Article. Such records must be retained for a period of not | 19 | | less than 6 years from the date of service or as provided by | 20 | | applicable State law, whichever period is longer, except that | 21 | | if an audit is initiated within the required retention period | 22 | | then the records must be retained until the audit is completed | 23 | | and every exception is resolved. The Illinois Department shall
| 24 | | require health care providers to make available, when | 25 | | authorized by the
patient, in writing, the medical records in a | 26 | | timely fashion to other
health care providers who are treating |
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| 1 | | or serving persons eligible for
Medical Assistance under this | 2 | | Article. All dispensers of medical services
shall be required | 3 | | to maintain and retain business and professional records
| 4 | | sufficient to fully and accurately document the nature, scope, | 5 | | details and
receipt of the health care provided to persons | 6 | | eligible for medical
assistance under this Code, in accordance | 7 | | with regulations promulgated by
the Illinois Department. The | 8 | | rules and regulations shall require that proof
of the receipt | 9 | | of prescription drugs, dentures, prosthetic devices and
| 10 | | eyeglasses by eligible persons under this Section accompany | 11 | | each claim
for reimbursement submitted by the dispenser of such | 12 | | medical services.
No such claims for reimbursement shall be | 13 | | approved for payment by the Illinois
Department without such | 14 | | proof of receipt, unless the Illinois Department
shall have put | 15 | | into effect and shall be operating a system of post-payment
| 16 | | audit and review which shall, on a sampling basis, be deemed | 17 | | adequate by
the Illinois Department to assure that such drugs, | 18 | | dentures, prosthetic
devices and eyeglasses for which payment | 19 | | is being made are actually being
received by eligible | 20 | | recipients. Within 90 days after the effective date of
this | 21 | | amendatory Act of 1984, the Illinois Department shall establish | 22 | | a
current list of acquisition costs for all prosthetic devices | 23 | | and any
other items recognized as medical equipment and | 24 | | supplies reimbursable under
this Article and shall update such | 25 | | list on a quarterly basis, except that
the acquisition costs of | 26 | | all prescription drugs shall be updated no
less frequently than |
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| 1 | | every 30 days as required by Section 5-5.12.
| 2 | | The rules and regulations of the Illinois Department shall | 3 | | require
that a written statement including the required opinion | 4 | | of a physician
shall accompany any claim for reimbursement for | 5 | | abortions, or induced
miscarriages or premature births. This | 6 | | statement shall indicate what
procedures were used in providing | 7 | | such medical services.
| 8 | | Notwithstanding any other law to the contrary, the Illinois | 9 | | Department shall, within 365 days after July 22, 2013 , (the | 10 | | effective date of Public Act 98-104), establish procedures to | 11 | | permit skilled care facilities licensed under the Nursing Home | 12 | | Care Act to submit monthly billing claims for reimbursement | 13 | | purposes. Following development of these procedures, the | 14 | | Department shall have an additional 365 days to test the | 15 | | viability of the new system and to ensure that any necessary | 16 | | operational or structural changes to its information | 17 | | technology platforms are implemented. | 18 | | Notwithstanding any other law to the contrary, the Illinois | 19 | | Department shall, within 365 days after August 15, 2014 ( the | 20 | | effective date of Public Act 98-963) this amendatory Act of the | 21 | | 98th General Assembly , establish procedures to permit ID/DD | 22 | | facilities licensed under the ID/DD Community Care Act to | 23 | | submit monthly billing claims for reimbursement purposes. | 24 | | Following development of these procedures, the Department | 25 | | shall have an additional 365 days to test the viability of the | 26 | | new system and to ensure that any necessary operational or |
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| 1 | | structural changes to its information technology platforms are | 2 | | implemented. | 3 | | The Illinois Department shall require all dispensers of | 4 | | medical
services, other than an individual practitioner or | 5 | | group of practitioners,
desiring to participate in the Medical | 6 | | Assistance program
established under this Article to disclose | 7 | | all financial, beneficial,
ownership, equity, surety or other | 8 | | interests in any and all firms,
corporations, partnerships, | 9 | | associations, business enterprises, joint
ventures, agencies, | 10 | | institutions or other legal entities providing any
form of | 11 | | health care services in this State under this Article.
| 12 | | The Illinois Department may require that all dispensers of | 13 | | medical
services desiring to participate in the medical | 14 | | assistance program
established under this Article disclose, | 15 | | under such terms and conditions as
the Illinois Department may | 16 | | by rule establish, all inquiries from clients
and attorneys | 17 | | regarding medical bills paid by the Illinois Department, which
| 18 | | inquiries could indicate potential existence of claims or liens | 19 | | for the
Illinois Department.
| 20 | | Enrollment of a vendor
shall be
subject to a provisional | 21 | | period and shall be conditional for one year. During the period | 22 | | of conditional enrollment, the Department may
terminate the | 23 | | vendor's eligibility to participate in, or may disenroll the | 24 | | vendor from, the medical assistance
program without cause. | 25 | | Unless otherwise specified, such termination of eligibility or | 26 | | disenrollment is not subject to the
Department's hearing |
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| 1 | | process.
However, a disenrolled vendor may reapply without | 2 | | penalty.
| 3 | | The Department has the discretion to limit the conditional | 4 | | enrollment period for vendors based upon category of risk of | 5 | | the vendor. | 6 | | Prior to enrollment and during the conditional enrollment | 7 | | period in the medical assistance program, all vendors shall be | 8 | | subject to enhanced oversight, screening, and review based on | 9 | | the risk of fraud, waste, and abuse that is posed by the | 10 | | category of risk of the vendor. The Illinois Department shall | 11 | | establish the procedures for oversight, screening, and review, | 12 | | which may include, but need not be limited to: criminal and | 13 | | financial background checks; fingerprinting; license, | 14 | | certification, and authorization verifications; unscheduled or | 15 | | unannounced site visits; database checks; prepayment audit | 16 | | reviews; audits; payment caps; payment suspensions; and other | 17 | | screening as required by federal or State law. | 18 | | The Department shall define or specify the following: (i) | 19 | | by provider notice, the "category of risk of the vendor" for | 20 | | each type of vendor, which shall take into account the level of | 21 | | screening applicable to a particular category of vendor under | 22 | | federal law and regulations; (ii) by rule or provider notice, | 23 | | the maximum length of the conditional enrollment period for | 24 | | each category of risk of the vendor; and (iii) by rule, the | 25 | | hearing rights, if any, afforded to a vendor in each category | 26 | | of risk of the vendor that is terminated or disenrolled during |
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| 1 | | the conditional enrollment period. | 2 | | To be eligible for payment consideration, a vendor's | 3 | | payment claim or bill, either as an initial claim or as a | 4 | | resubmitted claim following prior rejection, must be received | 5 | | by the Illinois Department, or its fiscal intermediary, no | 6 | | later than 180 days after the latest date on the claim on which | 7 | | medical goods or services were provided, with the following | 8 | | exceptions: | 9 | | (1) In the case of a provider whose enrollment is in | 10 | | process by the Illinois Department, the 180-day period | 11 | | shall not begin until the date on the written notice from | 12 | | the Illinois Department that the provider enrollment is | 13 | | complete. | 14 | | (2) In the case of errors attributable to the Illinois | 15 | | Department or any of its claims processing intermediaries | 16 | | which result in an inability to receive, process, or | 17 | | adjudicate a claim, the 180-day period shall not begin | 18 | | until the provider has been notified of the error. | 19 | | (3) In the case of a provider for whom the Illinois | 20 | | Department initiates the monthly billing process. | 21 | | (4) In the case of a provider operated by a unit of | 22 | | local government with a population exceeding 3,000,000 | 23 | | when local government funds finance federal participation | 24 | | for claims payments. | 25 | | For claims for services rendered during a period for which | 26 | | a recipient received retroactive eligibility, claims must be |
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| 1 | | filed within 180 days after the Department determines the | 2 | | applicant is eligible. For claims for which the Illinois | 3 | | Department is not the primary payer, claims must be submitted | 4 | | to the Illinois Department within 180 days after the final | 5 | | adjudication by the primary payer. | 6 | | In the case of long term care facilities, within 5 days of | 7 | | receipt by the facility of required prescreening information, | 8 | | data for new admissions shall be entered into the Medical | 9 | | Electronic Data Interchange (MEDI) or the Recipient | 10 | | Eligibility Verification (REV) System or successor system, and | 11 | | within 15 days of receipt by the facility of required | 12 | | prescreening information, admission documents shall be | 13 | | submitted through MEDI or REV or shall be submitted directly to | 14 | | the Department of Human Services using required admission | 15 | | forms. Effective September
1, 2014, admission documents, | 16 | | including all prescreening
information, must be submitted | 17 | | through MEDI or REV. Confirmation numbers assigned to an | 18 | | accepted transaction shall be retained by a facility to verify | 19 | | timely submittal. Once an admission transaction has been | 20 | | completed, all resubmitted claims following prior rejection | 21 | | are subject to receipt no later than 180 days after the | 22 | | admission transaction has been completed. | 23 | | Claims that are not submitted and received in compliance | 24 | | with the foregoing requirements shall not be eligible for | 25 | | payment under the medical assistance program, and the State | 26 | | shall have no liability for payment of those claims. |
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| 1 | | To the extent consistent with applicable information and | 2 | | privacy, security, and disclosure laws, State and federal | 3 | | agencies and departments shall provide the Illinois Department | 4 | | access to confidential and other information and data necessary | 5 | | to perform eligibility and payment verifications and other | 6 | | Illinois Department functions. This includes, but is not | 7 | | limited to: information pertaining to licensure; | 8 | | certification; earnings; immigration status; citizenship; wage | 9 | | reporting; unearned and earned income; pension income; | 10 | | employment; supplemental security income; social security | 11 | | numbers; National Provider Identifier (NPI) numbers; the | 12 | | National Practitioner Data Bank (NPDB); program and agency | 13 | | exclusions; taxpayer identification numbers; tax delinquency; | 14 | | corporate information; and death records. | 15 | | The Illinois Department shall enter into agreements with | 16 | | State agencies and departments, and is authorized to enter into | 17 | | agreements with federal agencies and departments, under which | 18 | | such agencies and departments shall share data necessary for | 19 | | medical assistance program integrity functions and oversight. | 20 | | The Illinois Department shall develop, in cooperation with | 21 | | other State departments and agencies, and in compliance with | 22 | | applicable federal laws and regulations, appropriate and | 23 | | effective methods to share such data. At a minimum, and to the | 24 | | extent necessary to provide data sharing, the Illinois | 25 | | Department shall enter into agreements with State agencies and | 26 | | departments, and is authorized to enter into agreements with |
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| 1 | | federal agencies and departments, including but not limited to: | 2 | | the Secretary of State; the Department of Revenue; the | 3 | | Department of Public Health; the Department of Human Services; | 4 | | and the Department of Financial and Professional Regulation. | 5 | | Beginning in fiscal year 2013, the Illinois Department | 6 | | shall set forth a request for information to identify the | 7 | | benefits of a pre-payment, post-adjudication, and post-edit | 8 | | claims system with the goals of streamlining claims processing | 9 | | and provider reimbursement, reducing the number of pending or | 10 | | rejected claims, and helping to ensure a more transparent | 11 | | adjudication process through the utilization of: (i) provider | 12 | | data verification and provider screening technology; and (ii) | 13 | | clinical code editing; and (iii) pre-pay, pre- or | 14 | | post-adjudicated predictive modeling with an integrated case | 15 | | management system with link analysis. Such a request for | 16 | | information shall not be considered as a request for proposal | 17 | | or as an obligation on the part of the Illinois Department to | 18 | | take any action or acquire any products or services. | 19 | | The Illinois Department shall establish policies, | 20 | | procedures,
standards and criteria by rule for the acquisition, | 21 | | repair and replacement
of orthotic and prosthetic devices and | 22 | | durable medical equipment. Such
rules shall provide, but not be | 23 | | limited to, the following services: (1)
immediate repair or | 24 | | replacement of such devices by recipients; and (2) rental, | 25 | | lease, purchase or lease-purchase of
durable medical equipment | 26 | | in a cost-effective manner, taking into
consideration the |
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| 1 | | recipient's medical prognosis, the extent of the
recipient's | 2 | | needs, and the requirements and costs for maintaining such
| 3 | | equipment. Subject to prior approval, such rules shall enable a | 4 | | recipient to temporarily acquire and
use alternative or | 5 | | substitute devices or equipment pending repairs or
| 6 | | replacements of any device or equipment previously authorized | 7 | | for such
recipient by the Department.
| 8 | | The Department shall execute, relative to the nursing home | 9 | | prescreening
project, written inter-agency agreements with the | 10 | | Department of Human
Services and the Department on Aging, to | 11 | | effect the following: (i) intake
procedures and common | 12 | | eligibility criteria for those persons who are receiving
| 13 | | non-institutional services; and (ii) the establishment and | 14 | | development of
non-institutional services in areas of the State | 15 | | where they are not currently
available or are undeveloped; and | 16 | | (iii) notwithstanding any other provision of law, subject to | 17 | | federal approval, on and after July 1, 2012, an increase in the | 18 | | determination of need (DON) scores from 29 to 37 for applicants | 19 | | for institutional and home and community-based long term care; | 20 | | if and only if federal approval is not granted, the Department | 21 | | may, in conjunction with other affected agencies, implement | 22 | | utilization controls or changes in benefit packages to | 23 | | effectuate a similar savings amount for this population; and | 24 | | (iv) no later than July 1, 2013, minimum level of care | 25 | | eligibility criteria for institutional and home and | 26 | | community-based long term care; and (v) no later than October |
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| 1 | | 1, 2013, establish procedures to permit long term care | 2 | | providers access to eligibility scores for individuals with an | 3 | | admission date who are seeking or receiving services from the | 4 | | long term care provider. In order to select the minimum level | 5 | | of care eligibility criteria, the Governor shall establish a | 6 | | workgroup that includes affected agency representatives and | 7 | | stakeholders representing the institutional and home and | 8 | | community-based long term care interests. This Section shall | 9 | | not restrict the Department from implementing lower level of | 10 | | care eligibility criteria for community-based services in | 11 | | circumstances where federal approval has been granted.
| 12 | | The Illinois Department shall develop and operate, in | 13 | | cooperation
with other State Departments and agencies and in | 14 | | compliance with
applicable federal laws and regulations, | 15 | | appropriate and effective
systems of health care evaluation and | 16 | | programs for monitoring of
utilization of health care services | 17 | | and facilities, as it affects
persons eligible for medical | 18 | | assistance under this Code.
| 19 | | The Illinois Department shall report annually to the | 20 | | General Assembly,
no later than the second Friday in April of | 21 | | 1979 and each year
thereafter, in regard to:
| 22 | | (a) actual statistics and trends in utilization of | 23 | | medical services by
public aid recipients;
| 24 | | (b) actual statistics and trends in the provision of | 25 | | the various medical
services by medical vendors;
| 26 | | (c) current rate structures and proposed changes in |
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| 1 | | those rate structures
for the various medical vendors; and
| 2 | | (d) efforts at utilization review and control by the | 3 | | Illinois Department.
| 4 | | The period covered by each report shall be the 3 years | 5 | | ending on the June
30 prior to the report. The report shall | 6 | | include suggested legislation
for consideration by the General | 7 | | Assembly. The filing of one copy of the
report with the | 8 | | Speaker, one copy with the Minority Leader and one copy
with | 9 | | the Clerk of the House of Representatives, one copy with the | 10 | | President,
one copy with the Minority Leader and one copy with | 11 | | the Secretary of the
Senate, one copy with the Legislative | 12 | | Research Unit, and such additional
copies
with the State | 13 | | Government Report Distribution Center for the General
Assembly | 14 | | as is required under paragraph (t) of Section 7 of the State
| 15 | | Library Act shall be deemed sufficient to comply with this | 16 | | Section.
| 17 | | Rulemaking authority to implement Public Act 95-1045, if | 18 | | any, is conditioned on the rules being adopted in accordance | 19 | | with all provisions of the Illinois Administrative Procedure | 20 | | Act and all rules and procedures of the Joint Committee on | 21 | | Administrative Rules; any purported rule not so adopted, for | 22 | | whatever reason, is unauthorized. | 23 | | On and after July 1, 2012, the Department shall reduce any | 24 | | rate of reimbursement for services or other payments or alter | 25 | | any methodologies authorized by this Code to reduce any rate of | 26 | | reimbursement for services or other payments in accordance with |
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| 1 | | Section 5-5e. | 2 | | Because kidney transplantation can be an appropriate, cost | 3 | | effective
alternative to renal dialysis when medically | 4 | | necessary and notwithstanding the provisions of Section 1-11 of | 5 | | this Code, beginning October 1, 2014, the Department shall | 6 | | cover kidney transplantation for noncitizens with end-stage | 7 | | renal disease who are not eligible for comprehensive medical | 8 | | benefits, who meet the residency requirements of Section 5-3 of | 9 | | this Code, and who would otherwise meet the financial | 10 | | requirements of the appropriate class of eligible persons under | 11 | | Section 5-2 of this Code. To qualify for coverage of kidney | 12 | | transplantation, such person must be receiving emergency renal | 13 | | dialysis services covered by the Department. Providers under | 14 | | this Section shall be prior approved and certified by the | 15 | | Department to perform kidney transplantation and the services | 16 | | under this Section shall be limited to services associated with | 17 | | kidney transplantation. | 18 | | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | 19 | | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | 20 | | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | 21 | | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, | 22 | | eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14; | 23 | | revised 10-2-14.)
| 24 | | Section 99. Effective date. This Act takes effect upon | 25 | | becoming law.".
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