State of Illinois
2017 and 2018


Introduced , by Rep. Elizabeth Hernandez


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that notwithstanding any other law to the contrary, the Department of Healthcare and Family Services shall not adopt any rule or enter into any contract that prohibits reimbursement under the medical assistance program to an eligible clinic for a dental encounter for services performed by an individual licensed to practice dentistry or dental hygiene under the Illinois Dental Practice Act. Effective immediately.

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HB5100LRB100 17821 KTG 33001 b

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



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



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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for persons
3who rely on treatment by spiritual means alone through prayer
4for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in the
25    diseases of the eye, or by an optometrist, whichever the
26    person may select.



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1    Notwithstanding any other provision of this Code and
2subject to federal approval, the Department may adopt rules to
3allow a dentist who is volunteering his or her service at no
4cost to render dental services through an enrolled
5not-for-profit health clinic without the dentist personally
6enrolling as a participating provider in the medical assistance
7program. A not-for-profit health clinic shall include a public
8health clinic or Federally Qualified Health Center or other
9enrolled provider, as determined by the Department, through
10which dental services covered under this Section are performed.
11The Department shall establish a process for payment of claims
12for reimbursement for covered dental services rendered under
13this provision.
14    The Illinois Department, by rule, may distinguish and
15classify the medical services to be provided only in accordance
16with the classes of persons designated in Section 5-2.
17    The Department of Healthcare and Family Services must
18provide coverage and reimbursement for amino acid-based
19elemental formulas, regardless of delivery method, for the
20diagnosis and treatment of (i) eosinophilic disorders and (ii)
21short bowel syndrome when the prescribing physician has issued
22a written order stating that the amino acid-based elemental
23formula is medically necessary.
24    The Illinois Department shall authorize the provision of,
25and shall authorize payment for, screening by low-dose
26mammography for the presence of occult breast cancer for women



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135 years of age or older who are eligible for medical
2assistance under this Article, as follows:
3        (A) A baseline mammogram for women 35 to 39 years of
4    age.
5        (B) An annual mammogram for women 40 years of age or
6    older.
7        (C) A mammogram at the age and intervals considered
8    medically necessary by the woman's health care provider for
9    women under 40 years of age and having a family history of
10    breast cancer, prior personal history of breast cancer,
11    positive genetic testing, or other risk factors.
12        (D) A comprehensive ultrasound screening and MRI of an
13    entire breast or breasts if a mammogram demonstrates
14    heterogeneous or dense breast tissue, when medically
15    necessary as determined by a physician licensed to practice
16    medicine in all of its branches.
17        (E) A screening MRI when medically necessary, as
18    determined by a physician licensed to practice medicine in
19    all of its branches.
20    All screenings shall include a physical breast exam,
21instruction on self-examination and information regarding the
22frequency of self-examination and its value as a preventative
23tool. For purposes of this Section, "low-dose mammography"
24means the x-ray examination of the breast using equipment
25dedicated specifically for mammography, including the x-ray
26tube, filter, compression device, and image receptor, with an



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1average radiation exposure delivery of less than one rad per
2breast for 2 views of an average size breast. The term also
3includes digital mammography and includes breast
4tomosynthesis. As used in this Section, the term "breast
5tomosynthesis" means a radiologic procedure that involves the
6acquisition of projection images over the stationary breast to
7produce cross-sectional digital three-dimensional images of
8the breast. If, at any time, the Secretary of the United States
9Department of Health and Human Services, or its successor
10agency, promulgates rules or regulations to be published in the
11Federal Register or publishes a comment in the Federal Register
12or issues an opinion, guidance, or other action that would
13require the State, pursuant to any provision of the Patient
14Protection and Affordable Care Act (Public Law 111-148),
15including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
16successor provision, to defray the cost of any coverage for
17breast tomosynthesis outlined in this paragraph, then the
18requirement that an insurer cover breast tomosynthesis is
19inoperative other than any such coverage authorized under
20Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
21the State shall not assume any obligation for the cost of
22coverage for breast tomosynthesis set forth in this paragraph.
23    On and after January 1, 2016, the Department shall ensure
24that all networks of care for adult clients of the Department
25include access to at least one breast imaging Center of Imaging
26Excellence as certified by the American College of Radiology.



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1    On and after January 1, 2012, providers participating in a
2quality improvement program approved by the Department shall be
3reimbursed for screening and diagnostic mammography at the same
4rate as the Medicare program's rates, including the increased
5reimbursement for digital mammography.
6    The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10    On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16    The Department shall convene an expert panel, including
17representatives of hospitals, free standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the



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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7The Department shall work with experts in breast cancer
8outreach and patient navigation to optimize these reminders and
9shall establish a methodology for evaluating their
10effectiveness and modifying the methodology based on the
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. On or after July 1,
252016, the pilot program shall be expanded to include one site
26in western Illinois, one site in southern Illinois, one site in



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1central Illinois, and 4 sites within metropolitan Chicago. An
2evaluation of the pilot program shall be carried out measuring
3health outcomes and cost of care for those served by the pilot
4program compared to similarly situated patients who are not
5served by the pilot program.
6    The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include access
11for patients diagnosed with cancer to at least one academic
12commission on cancer-accredited cancer program as an
13in-network covered benefit.
14    Any medical or health care provider shall immediately
15recommend, to any pregnant woman who is being provided prenatal
16services and is suspected of drug abuse or is addicted as
17defined in the Alcoholism and Other Drug Abuse and Dependency
18Act, referral to a local substance abuse treatment provider
19licensed by the Department of Human Services or to a licensed
20hospital which provides substance abuse treatment services.
21The Department of Healthcare and Family Services shall assure
22coverage for the cost of treatment of the drug abuse or
23addiction for pregnant recipients in accordance with the
24Illinois Medicaid Program in conjunction with the Department of
25Human Services.
26    All medical providers providing medical assistance to



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



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1procedures to the Illinois Department.
2    The Illinois Department may develop and contract with
3Partnerships of medical providers to arrange medical services
4for persons eligible under Section 5-2 of this Code.
5Implementation of this Section may be by demonstration projects
6in certain geographic areas. The Partnership shall be
7represented by a sponsor organization. The Department, by rule,
8shall develop qualifications for sponsors of Partnerships.
9Nothing in this Section shall be construed to require that the
10sponsor organization be a medical organization.
11    The sponsor must negotiate formal written contracts with
12medical providers for physician services, inpatient and
13outpatient hospital care, home health services, treatment for
14alcoholism and substance abuse, and other services determined
15necessary by the Illinois Department by rule for delivery by
16Partnerships. Physician services must include prenatal and
17obstetrical care. The Illinois Department shall reimburse
18medical services delivered by Partnership providers to clients
19in target areas according to provisions of this Article and the
20Illinois Health Finance Reform Act, except that:
21        (1) Physicians participating in a Partnership and
22    providing certain services, which shall be determined by
23    the Illinois Department, to persons in areas covered by the
24    Partnership may receive an additional surcharge for such
25    services.
26        (2) The Department may elect to consider and negotiate



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1    financial incentives to encourage the development of
2    Partnerships and the efficient delivery of medical care.
3        (3) Persons receiving medical services through
4    Partnerships may receive medical and case management
5    services above the level usually offered through the
6    medical assistance program.
7    Medical providers shall be required to meet certain
8qualifications to participate in Partnerships to ensure the
9delivery of high quality medical services. These
10qualifications shall be determined by rule of the Illinois
11Department and may be higher than qualifications for
12participation in the medical assistance program. Partnership
13sponsors may prescribe reasonable additional qualifications
14for participation by medical providers, only with the prior
15written approval of the Illinois Department.
16    Nothing in this Section shall limit the free choice of
17practitioners, hospitals, and other providers of medical
18services by clients. In order to ensure patient freedom of
19choice, the Illinois Department shall immediately promulgate
20all rules and take all other necessary actions so that provided
21services may be accessed from therapeutically certified
22optometrists to the full extent of the Illinois Optometric
23Practice Act of 1987 without discriminating between service
25    The Department shall apply for a waiver from the United
26States Health Care Financing Administration to allow for the



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1implementation of Partnerships under this Section.
2    The Illinois Department shall require health care
3providers to maintain records that document the medical care
4and services provided to recipients of Medical Assistance under
5this Article. Such records must be retained for a period of not
6less than 6 years from the date of service or as provided by
7applicable State law, whichever period is longer, except that
8if an audit is initiated within the required retention period
9then the records must be retained until the audit is completed
10and every exception is resolved. The Illinois Department shall
11require health care providers to make available, when
12authorized by the patient, in writing, the medical records in a
13timely fashion to other health care providers who are treating
14or serving persons eligible for Medical Assistance under this
15Article. All dispensers of medical services shall be required
16to maintain and retain business and professional records
17sufficient to fully and accurately document the nature, scope,
18details and receipt of the health care provided to persons
19eligible for medical assistance under this Code, in accordance
20with regulations promulgated by the Illinois Department. The
21rules and regulations shall require that proof of the receipt
22of prescription drugs, dentures, prosthetic devices and
23eyeglasses by eligible persons under this Section accompany
24each claim for reimbursement submitted by the dispenser of such
25medical services. No such claims for reimbursement shall be
26approved for payment by the Illinois Department without such



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1proof of receipt, unless the Illinois Department shall have put
2into effect and shall be operating a system of post-payment
3audit and review which shall, on a sampling basis, be deemed
4adequate by the Illinois Department to assure that such drugs,
5dentures, prosthetic devices and eyeglasses for which payment
6is being made are actually being received by eligible
7recipients. Within 90 days after September 16, 1984 (the
8effective date of Public Act 83-1439), the Illinois Department
9shall establish a current list of acquisition costs for all
10prosthetic devices and any other items recognized as medical
11equipment and supplies reimbursable under this Article and
12shall update such list on a quarterly basis, except that the
13acquisition costs of all prescription drugs shall be updated no
14less frequently than every 30 days as required by Section
16    Notwithstanding any other law to the contrary, the Illinois
17Department shall, within 365 days after July 22, 2013 (the
18effective date of Public Act 98-104), establish procedures to
19permit skilled care facilities licensed under the Nursing Home
20Care Act to submit monthly billing claims for reimbursement
21purposes. Following development of these procedures, the
22Department shall, by July 1, 2016, test the viability of the
23new system and implement any necessary operational or
24structural changes to its information technology platforms in
25order to allow for the direct acceptance and payment of nursing
26home claims.



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



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



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1by provider notice, the "category of risk of the vendor" for
2each type of vendor, which shall take into account the level of
3screening applicable to a particular category of vendor under
4federal law and regulations; (ii) by rule or provider notice,
5the maximum length of the conditional enrollment period for
6each category of risk of the vendor; and (iii) by rule, the
7hearing rights, if any, afforded to a vendor in each category
8of risk of the vendor that is terminated or disenrolled during
9the conditional enrollment period.
10    To be eligible for payment consideration, a vendor's
11payment claim or bill, either as an initial claim or as a
12resubmitted claim following prior rejection, must be received
13by the Illinois Department, or its fiscal intermediary, no
14later than 180 days after the latest date on the claim on which
15medical goods or services were provided, with the following
17        (1) In the case of a provider whose enrollment is in
18    process by the Illinois Department, the 180-day period
19    shall not begin until the date on the written notice from
20    the Illinois Department that the provider enrollment is
21    complete.
22        (2) In the case of errors attributable to the Illinois
23    Department or any of its claims processing intermediaries
24    which result in an inability to receive, process, or
25    adjudicate a claim, the 180-day period shall not begin
26    until the provider has been notified of the error.



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1        (3) In the case of a provider for whom the Illinois
2    Department initiates the monthly billing process.
3        (4) In the case of a provider operated by a unit of
4    local government with a population exceeding 3,000,000
5    when local government funds finance federal participation
6    for claims payments.
7    For claims for services rendered during a period for which
8a recipient received retroactive eligibility, claims must be
9filed within 180 days after the Department determines the
10applicant is eligible. For claims for which the Illinois
11Department is not the primary payer, claims must be submitted
12to the Illinois Department within 180 days after the final
13adjudication by the primary payer.
14    In the case of long term care facilities, within 45
15calendar days of receipt by the facility of required
16prescreening information, new admissions with associated
17admission documents shall be submitted through the Medical
18Electronic Data Interchange (MEDI) or the Recipient
19Eligibility Verification (REV) System or shall be submitted
20directly to the Department of Human Services using required
21admission forms. Effective September 1, 2014, admission
22documents, including all prescreening information, must be
23submitted through MEDI or REV. Confirmation numbers assigned to
24an accepted transaction shall be retained by a facility to
25verify timely submittal. Once an admission transaction has been
26completed, all resubmitted claims following prior rejection



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



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



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1repair and replacement of orthotic and prosthetic devices and
2durable medical equipment. Such rules shall provide, but not be
3limited to, the following services: (1) immediate repair or
4replacement of such devices by recipients; and (2) rental,
5lease, purchase or lease-purchase of durable medical equipment
6in a cost-effective manner, taking into consideration the
7recipient's medical prognosis, the extent of the recipient's
8needs, and the requirements and costs for maintaining such
9equipment. Subject to prior approval, such rules shall enable a
10recipient to temporarily acquire and use alternative or
11substitute devices or equipment pending repairs or
12replacements of any device or equipment previously authorized
13for such recipient by the Department. Notwithstanding any
14provision of Section 5-5f to the contrary, the Department may,
15by rule, exempt certain replacement wheelchair parts from prior
16approval and, for wheelchairs, wheelchair parts, wheelchair
17accessories, and related seating and positioning items,
18determine the wholesale price by methods other than actual
19acquisition costs.
20    The Department shall require, by rule, all providers of
21durable medical equipment to be accredited by an accreditation
22organization approved by the federal Centers for Medicare and
23Medicaid Services and recognized by the Department in order to
24bill the Department for providing durable medical equipment to
25recipients. No later than 15 months after the effective date of
26the rule adopted pursuant to this paragraph, all providers must



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1meet the accreditation requirement.
2    The Department shall execute, relative to the nursing home
3prescreening project, written inter-agency agreements with the
4Department of Human Services and the Department on Aging, to
5effect the following: (i) intake procedures and common
6eligibility criteria for those persons who are receiving
7non-institutional services; and (ii) the establishment and
8development of non-institutional services in areas of the State
9where they are not currently available or are undeveloped; and
10(iii) notwithstanding any other provision of law, subject to
11federal approval, on and after July 1, 2012, an increase in the
12determination of need (DON) scores from 29 to 37 for applicants
13for institutional and home and community-based long term care;
14if and only if federal approval is not granted, the Department
15may, in conjunction with other affected agencies, implement
16utilization controls or changes in benefit packages to
17effectuate a similar savings amount for this population; and
18(iv) no later than July 1, 2013, minimum level of care
19eligibility criteria for institutional and home and
20community-based long term care; and (v) no later than October
211, 2013, establish procedures to permit long term care
22providers access to eligibility scores for individuals with an
23admission date who are seeking or receiving services from the
24long term care provider. In order to select the minimum level
25of care eligibility criteria, the Governor shall establish a
26workgroup that includes affected agency representatives and



HB5100- 24 -LRB100 17821 KTG 33001 b

1stakeholders representing the institutional and home and
2community-based long term care interests. This Section shall
3not restrict the Department from implementing lower level of
4care eligibility criteria for community-based services in
5circumstances where federal approval has been granted.
6    The Illinois Department shall develop and operate, in
7cooperation with other State Departments and agencies and in
8compliance with applicable federal laws and regulations,
9appropriate and effective systems of health care evaluation and
10programs for monitoring of utilization of health care services
11and facilities, as it affects persons eligible for medical
12assistance under this Code.
13    The Illinois Department shall report annually to the
14General Assembly, no later than the second Friday in April of
151979 and each year thereafter, in regard to:
16        (a) actual statistics and trends in utilization of
17    medical services by public aid recipients;
18        (b) actual statistics and trends in the provision of
19    the various medical services by medical vendors;
20        (c) current rate structures and proposed changes in
21    those rate structures for the various medical vendors; and
22        (d) efforts at utilization review and control by the
23    Illinois Department.
24    The period covered by each report shall be the 3 years
25ending on the June 30 prior to the report. The report shall
26include suggested legislation for consideration by the General



HB5100- 25 -LRB100 17821 KTG 33001 b

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



HB5100- 26 -LRB100 17821 KTG 33001 b

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



HB5100- 27 -LRB100 17821 KTG 33001 b

1shall be covered under the medical assistance program for
2persons who are otherwise eligible for medical assistance under
3this Article. As used in this Section, "opioid antagonist"
4means a drug that binds to opioid receptors and blocks or
5inhibits the effect of opioids acting on those receptors,
6including, but not limited to, naloxone hydrochloride or any
7other similarly acting drug approved by the U.S. Food and Drug
9    Upon federal approval, the Department shall provide
10coverage and reimbursement for all drugs that are approved for
11marketing by the federal Food and Drug Administration and that
12are recommended by the federal Public Health Service or the
13United States Centers for Disease Control and Prevention for
14pre-exposure prophylaxis and related pre-exposure prophylaxis
15services, including, but not limited to, HIV and sexually
16transmitted infection screening, treatment for sexually
17transmitted infections, medical monitoring, assorted labs, and
18counseling to reduce the likelihood of HIV infection among
19individuals who are not infected with HIV but who are at high
20risk of HIV infection.
21    Notwithstanding any other law to the contrary, the
22Department shall not adopt any rule or enter into any contract
23that prohibits reimbursement under the medical assistance
24program to an eligible clinic for a dental encounter for
25services performed by an individual licensed to practice
26dentistry or dental hygiene under the Illinois Dental Practice



HB5100- 28 -LRB100 17821 KTG 33001 b

2(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
399-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
4the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
599-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
67-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
7eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
8100-538, eff. 1-1-18; revised 10-26-17.)
9    Section 99. Effective date. This Act takes effect upon
10becoming law.