State of Illinois
2015 and 2016


Introduced 1/27/2016, by Sen. Heather A. Steans


305 ILCS 5/5-5f

    Amends the Illinois Public Aid Code. Makes a technical change in a Section concerning elimination and limitations of medical assistance services.

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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5f as follows:
6    (305 ILCS 5/5-5f)
7    Sec. 5-5f. Elimination and limitations of medical
8assistance services. Notwithstanding any any other provision
9of this Code to the contrary, on and after July 1, 2012:
10        (a) The following services shall no longer be a covered
11    service available under this Code: group psychotherapy for
12    residents of any facility licensed under the Nursing Home
13    Care Act or the Specialized Mental Health Rehabilitation
14    Act of 2013; and adult chiropractic services.
15        (b) The Department shall place the following
16    limitations on services: (i) the Department shall limit
17    adult eyeglasses to one pair every 2 years; (ii) the
18    Department shall set an annual limit of a maximum of 20
19    visits for each of the following services: adult speech,
20    hearing, and language therapy services, adult occupational
21    therapy services, and physical therapy services; on or
22    after October 1, 2014, the annual maximum limit of 20
23    visits shall expire but the Department shall require prior



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1    approval for all individuals for speech, hearing, and
2    language therapy services, occupational therapy services,
3    and physical therapy services; (iii) the Department shall
4    limit adult podiatry services to individuals with
5    diabetes; on or after October 1, 2014, podiatry services
6    shall not be limited to individuals with diabetes; (iv) the
7    Department shall pay for caesarean sections at the normal
8    vaginal delivery rate unless a caesarean section was
9    medically necessary; (v) the Department shall limit adult
10    dental services to emergencies; beginning July 1, 2013, the
11    Department shall ensure that the following conditions are
12    recognized as emergencies: (A) dental services necessary
13    for an individual in order for the individual to be cleared
14    for a medical procedure, such as a transplant; (B)
15    extractions and dentures necessary for a diabetic to
16    receive proper nutrition; (C) extractions and dentures
17    necessary as a result of cancer treatment; and (D) dental
18    services necessary for the health of a pregnant woman prior
19    to delivery of her baby; on or after July 1, 2014, adult
20    dental services shall no longer be limited to emergencies,
21    and dental services necessary for the health of a pregnant
22    woman prior to delivery of her baby shall continue to be
23    covered; and (vi) effective July 1, 2012, the Department
24    shall place limitations and require concurrent review on
25    every inpatient detoxification stay to prevent repeat
26    admissions to any hospital for detoxification within 60



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1    days of a previous inpatient detoxification stay. The
2    Department shall convene a workgroup of hospitals,
3    substance abuse providers, care coordination entities,
4    managed care plans, and other stakeholders to develop
5    recommendations for quality standards, diversion to other
6    settings, and admission criteria for patients who need
7    inpatient detoxification, which shall be published on the
8    Department's website no later than September 1, 2013.
9        (c) The Department shall require prior approval of the
10    following services: wheelchair repairs costing more than
11    $400, coronary artery bypass graft, and bariatric surgery
12    consistent with Medicare standards concerning patient
13    responsibility. Wheelchair repair prior approval requests
14    shall be adjudicated within one business day of receipt of
15    complete supporting documentation. Providers may not break
16    wheelchair repairs into separate claims for purposes of
17    staying under the $400 threshold for requiring prior
18    approval. The wholesale price of manual and power
19    wheelchairs, durable medical equipment and supplies, and
20    complex rehabilitation technology products and services
21    shall be defined as actual acquisition cost including all
22    discounts.
23        (d) The Department shall establish benchmarks for
24    hospitals to measure and align payments to reduce
25    potentially preventable hospital readmissions, inpatient
26    complications, and unnecessary emergency room visits. In



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1    doing so, the Department shall consider items, including,
2    but not limited to, historic and current acuity of care and
3    historic and current trends in readmission. The Department
4    shall publish provider-specific historical readmission
5    data and anticipated potentially preventable targets 60
6    days prior to the start of the program. In the instance of
7    readmissions, the Department shall adopt policies and
8    rates of reimbursement for services and other payments
9    provided under this Code to ensure that, by June 30, 2013,
10    expenditures to hospitals are reduced by, at a minimum,
11    $40,000,000.
12        (e) The Department shall establish utilization
13    controls for the hospice program such that it shall not pay
14    for other care services when an individual is in hospice.
15        (f) For home health services, the Department shall
16    require Medicare certification of providers participating
17    in the program and implement the Medicare face-to-face
18    encounter rule. The Department shall require providers to
19    implement auditable electronic service verification based
20    on global positioning systems or other cost-effective
21    technology.
22        (g) For the Home Services Program operated by the
23    Department of Human Services and the Community Care Program
24    operated by the Department on Aging, the Department of
25    Human Services, in cooperation with the Department on
26    Aging, shall implement an electronic service verification



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1    based on global positioning systems or other
2    cost-effective technology.
3        (h) Effective with inpatient hospital admissions on or
4    after July 1, 2012, the Department shall reduce the payment
5    for a claim that indicates the occurrence of a
6    provider-preventable condition during the admission as
7    specified by the Department in rules. The Department shall
8    not pay for services related to an other
9    provider-preventable condition.
10        As used in this subsection (h):
11        "Provider-preventable condition" means a health care
12    acquired condition as defined under the federal Medicaid
13    regulation found at 42 CFR 447.26 or an other
14    provider-preventable condition.
15        "Other provider-preventable condition" means a wrong
16    surgical or other invasive procedure performed on a
17    patient, a surgical or other invasive procedure performed
18    on the wrong body part, or a surgical procedure or other
19    invasive procedure performed on the wrong patient.
20        (i) The Department shall implement cost savings
21    initiatives for advanced imaging services, cardiac imaging
22    services, pain management services, and back surgery. Such
23    initiatives shall be designed to achieve annual costs
24    savings.
25        (j) The Department shall ensure that beneficiaries
26    with a diagnosis of epilepsy or seizure disorder in



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1    Department records will not require prior approval for
2    anticonvulsants.
3(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
46-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff.
57-22-13; 98-651, eff. 6-16-14; 98-756, eff. 7-16-14.)