Full Text of HB2589 102nd General Assembly
HB2589sam001 102ND GENERAL ASSEMBLY | Sen. Laura Fine Filed: 5/13/2021
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| 1 | | AMENDMENT TO HOUSE BILL 2589
| 2 | | AMENDMENT NO. ______. Amend House Bill 2589 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Substance Use Disorder Act is amended by | 5 | | changing Sections 5-23 and 20-10 as follows: | 6 | | (20 ILCS 301/5-23) | 7 | | Sec. 5-23. Drug Overdose Prevention Program. | 8 | | (a) Reports. | 9 | | (1) The Department may publish annually a report on | 10 | | drug overdose trends statewide that reviews State death | 11 | | rates from available data to ascertain changes in the | 12 | | causes or rates of fatal and nonfatal drug overdose. The | 13 | | report shall also provide information on interventions | 14 | | that would be effective in reducing the rate of fatal or | 15 | | nonfatal drug overdose and on the current substance use | 16 | | disorder treatment capacity within the State. The report |
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| 1 | | shall include an analysis of drug overdose information | 2 | | reported to the Department of Public Health pursuant to | 3 | | subsection (e) of Section 3-3013 of the Counties Code, | 4 | | Section 6.14g of the Hospital Licensing Act, and | 5 | | subsection (j) of Section 22-30 of the School Code. | 6 | | (2) The report may include: | 7 | | (A) Trends in drug overdose death rates. | 8 | | (B) Trends in emergency room utilization related | 9 | | to drug overdose and the cost impact of emergency room | 10 | | utilization. | 11 | | (C) Trends in utilization of pre-hospital and | 12 | | emergency services and the cost impact of emergency | 13 | | services utilization. | 14 | | (D) Suggested improvements in data collection. | 15 | | (E) A description of other interventions effective | 16 | | in reducing the rate of fatal or nonfatal drug | 17 | | overdose. | 18 | | (F) A description of efforts undertaken to educate | 19 | | the public about unused medication and about how to | 20 | | properly dispose of unused medication, including the | 21 | | number of registered collection receptacles in this | 22 | | State, mail-back programs, and drug take-back events. | 23 | | (G) An inventory of the State's substance use | 24 | | disorder treatment capacity, including, but not | 25 | | limited to: | 26 | | (i) The number and type of licensed treatment |
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| 1 | | programs in each geographic area of the State. | 2 | | (ii) The availability of medication-assisted | 3 | | treatment at each licensed program and which types | 4 | | of medication-assisted treatment are available. | 5 | | (iii) The number of recovery homes that accept | 6 | | individuals using medication-assisted treatment in | 7 | | their recovery. | 8 | | (iv) The number of medical professionals | 9 | | currently authorized to prescribe buprenorphine | 10 | | and the number of individuals who fill | 11 | | prescriptions for that medication at retail | 12 | | pharmacies as prescribed. | 13 | | (v) Any partnerships between programs licensed | 14 | | by the Department and other providers of | 15 | | medication-assisted treatment. | 16 | | (vi) Any challenges in providing | 17 | | medication-assisted treatment reported by programs | 18 | | licensed by the Department and any potential | 19 | | solutions. | 20 | | (b) Programs; drug overdose prevention. | 21 | | (1) The Department may establish a program to provide | 22 | | for the production and publication, in electronic and | 23 | | other formats, of drug overdose prevention, recognition, | 24 | | and response literature. The Department may develop and | 25 | | disseminate curricula for use by professionals, | 26 | | organizations, individuals, or committees interested in |
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| 1 | | the prevention of fatal and nonfatal drug overdose, | 2 | | including, but not limited to, drug users, jail and prison | 3 | | personnel, jail and prison inmates, drug treatment | 4 | | professionals, emergency medical personnel, hospital | 5 | | staff, families and associates of drug users, peace | 6 | | officers, firefighters, public safety officers, needle | 7 | | exchange program staff, and other persons. In addition to | 8 | | information regarding drug overdose prevention, | 9 | | recognition, and response, literature produced by the | 10 | | Department shall stress that drug use remains illegal and | 11 | | highly dangerous and that complete abstinence from illegal | 12 | | drug use is the healthiest choice. The literature shall | 13 | | provide information and resources for substance use | 14 | | disorder treatment. | 15 | | The Department may establish or authorize programs for | 16 | | prescribing, dispensing, or distributing opioid | 17 | | antagonists for the treatment of drug overdose. Such | 18 | | programs may include the prescribing of opioid antagonists | 19 | | for the treatment of drug overdose to a person who is not | 20 | | at risk of opioid overdose but who, in the judgment of the | 21 | | health care professional, may be in a position to assist | 22 | | another individual during an opioid-related drug overdose | 23 | | and who has received basic instruction on how to | 24 | | administer an opioid antagonist. | 25 | | (2) The Department may provide advice to State and | 26 | | local officials on the growing drug overdose crisis, |
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| 1 | | including the prevalence of drug overdose incidents, | 2 | | programs promoting the disposal of unused prescription | 3 | | drugs, trends in drug overdose incidents, and solutions to | 4 | | the drug overdose crisis. | 5 | | (3) The Department may support drug overdose | 6 | | prevention, recognition, and response projects by | 7 | | facilitating the acquisition of opioid antagonist | 8 | | medication approved for opioid overdose reversal, | 9 | | facilitating the acquisition of opioid antagonist | 10 | | medication approved for opioid overdose reversal, | 11 | | providing trainings in overdose prevention best practices, | 12 | | connecting programs to medical resources, establishing a | 13 | | statewide standing order for the acquisition of needed | 14 | | medication, establishing learning collaboratives between | 15 | | localities and programs, and assisting programs in | 16 | | navigating any regulatory requirements for establishing or | 17 | | expanding such programs. | 18 | | (4) In supporting best practices in drug overdose | 19 | | prevention programming, the Department may promote the | 20 | | following programmatic elements: | 21 | | (A) Training individuals who currently use drugs | 22 | | in the administration of opioid antagonists approved | 23 | | for the reversal of an opioid overdose. | 24 | | (B) Directly distributing opioid antagonists | 25 | | approved for the reversal of an opioid overdose rather | 26 | | than providing prescriptions to be filled at a |
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| 1 | | pharmacy. | 2 | | (C) Conducting street and community outreach to | 3 | | work directly with individuals who are using drugs. | 4 | | (D) Employing community health workers or peer | 5 | | recovery specialists who are familiar with the | 6 | | communities served and can provide culturally | 7 | | competent services. | 8 | | (E) Collaborating with other community-based | 9 | | organizations, substance use disorder treatment | 10 | | centers, or other health care providers engaged in | 11 | | treating individuals who are using drugs. | 12 | | (F) Providing linkages for individuals to obtain | 13 | | evidence-based substance use disorder treatment. | 14 | | (G) Engaging individuals exiting jails or prisons | 15 | | who are at a high risk of overdose. | 16 | | (H) Providing education and training to | 17 | | community-based organizations who work directly with | 18 | | individuals who are using drugs and those individuals' | 19 | | families and communities. | 20 | | (I) Providing education and training on drug | 21 | | overdose prevention and response to emergency | 22 | | personnel and law enforcement. | 23 | | (J) Informing communities of the important role | 24 | | emergency personnel play in responding to accidental | 25 | | overdose. | 26 | | (K) Producing and distributing targeted mass media |
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| 1 | | materials on drug overdose prevention and response, | 2 | | the potential dangers of leaving unused prescription | 3 | | drugs in the home, and the proper methods for | 4 | | disposing of unused prescription drugs. | 5 | | (c) Grants. | 6 | | (1) The Department may award grants, in accordance | 7 | | with this subsection, to create or support local drug | 8 | | overdose prevention, recognition, and response projects. | 9 | | Local health departments, correctional institutions, | 10 | | hospitals, universities, community-based organizations, | 11 | | and faith-based organizations may apply to the Department | 12 | | for a grant under this subsection at the time and in the | 13 | | manner the Department prescribes. Eligible grant | 14 | | activities include, but are not limited to, purchasing and | 15 | | distributing opioid antagonists, hiring peer recovery | 16 | | specialists or other community members to conduct | 17 | | community outreach, and hosting public health fairs or | 18 | | events to distribute opioid antagonists, promote harm | 19 | | reduction activities, and provide linkages to community | 20 | | partners. | 21 | | (2) In awarding grants, the Department shall consider | 22 | | the overall rate of opioid overdose, the rate of increase | 23 | | in opioid overdose, and racial disparities in opioid | 24 | | overdose experienced by the communities to be served by | 25 | | grantees. The Department necessity for overdose prevention | 26 | | projects in various settings and shall encourage all grant |
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| 1 | | applicants to develop interventions that will be effective | 2 | | and viable in their local areas. | 3 | | (3) (Blank). | 4 | | (3.5) Any hospital licensed under the Hospital | 5 | | Licensing Act or organized under the University of | 6 | | Illinois Hospital Act shall be deemed to
have met the | 7 | | standards and requirements set forth in this Section to | 8 | | enroll in the drug overdose prevention program upon | 9 | | completion of
the enrollment process except that proof of | 10 | | a standing order and attestation of programmatic | 11 | | requirements shall
be waived for enrollment purposes. | 12 | | Reporting mandated by enrollment
shall be necessary to | 13 | | carry out or attain eligibility for associated resources | 14 | | under this Section for drug overdose prevention projects
| 15 | | operated on the licensed premises of the hospital and | 16 | | operated by the hospital or its designated agent. The | 17 | | Department shall streamline hospital enrollment for drug | 18 | | overdose prevention programs by accepting such deemed | 19 | | status under this Section
in order to reduce barriers to | 20 | | hospital participation in drug overdose prevention, | 21 | | recognition, or response projects. | 22 | | (4) In addition to moneys appropriated by the General | 23 | | Assembly, the Department may seek grants from private | 24 | | foundations, the federal government, and other sources to | 25 | | fund the grants under this Section and to fund an | 26 | | evaluation of the programs supported by the grants. |
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| 1 | | (d) Health care professional prescription of opioid | 2 | | antagonists. | 3 | | (1) A health care professional who, acting in good | 4 | | faith, directly or by standing order, prescribes or | 5 | | dispenses an opioid antagonist to: (a) a patient who, in | 6 | | the judgment of the health care professional, is capable | 7 | | of administering the drug in an emergency, or (b) a person | 8 | | who is not at risk of opioid overdose but who, in the | 9 | | judgment of the health care professional, may be in a | 10 | | position to assist another individual during an | 11 | | opioid-related drug overdose and who has received basic | 12 | | instruction on how to administer an opioid antagonist | 13 | | shall not, as a result of his or her acts or omissions, be | 14 | | subject to: (i) any disciplinary or other adverse action | 15 | | under the Medical Practice Act of 1987, the Physician | 16 | | Assistant Practice Act of 1987, the Nurse Practice Act, | 17 | | the Pharmacy Practice Act, or any other professional | 18 | | licensing statute or (ii) any criminal liability, except | 19 | | for willful and wanton misconduct. | 20 | | (1.5) Notwithstanding any provision of or requirement | 21 | | otherwise imposed by the Pharmacy Practice Act, the | 22 | | Medical Practice Act of 1987, or any other law or rule, | 23 | | including, but not limited to, any requirement related to | 24 | | labeling, storage, or recordkeeping, a health care | 25 | | professional or other person acting under the direction of | 26 | | a health care professional may, directly or by standing |
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| 1 | | order, obtain, store, and dispense an
opioid antagonist to | 2 | | a patient in a facility that includes, but is not limited | 3 | | to, a hospital, a hospital affiliate, or a federally
| 4 | | qualified health center if the patient information | 5 | | specified in paragraph (4) of this subsection is provided | 6 | | to the patient. A person acting in accordance with this | 7 | | paragraph shall not, as a result of his or her acts or | 8 | | omissions, be subject to: (i) any disciplinary or other | 9 | | adverse action under the Medical Practice Act of 1987, the | 10 | | Physician Assistant Practice Act of 1987, the Nurse | 11 | | Practice Act, the Pharmacy Practice Act, or any other | 12 | | professional licensing statute; or (ii) any criminal | 13 | | liability, except for willful and wanton misconduct. | 14 | | (2) A person who is not otherwise licensed to | 15 | | administer an opioid antagonist may in an emergency | 16 | | administer without fee an opioid antagonist if the person | 17 | | has received the patient information specified in | 18 | | paragraph (4) of this subsection and believes in good | 19 | | faith that another person is experiencing a drug overdose. | 20 | | The person shall not, as a result of his or her acts or | 21 | | omissions, be (i) liable for any violation of the Medical | 22 | | Practice Act of 1987, the Physician Assistant Practice Act | 23 | | of 1987, the Nurse Practice Act, the Pharmacy Practice | 24 | | Act, or any other professional licensing statute, or (ii) | 25 | | subject to any criminal prosecution or civil liability, | 26 | | except for willful and wanton misconduct. |
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| 1 | | (3) A health care professional prescribing an opioid | 2 | | antagonist to a patient shall ensure that the patient | 3 | | receives the patient information specified in paragraph | 4 | | (4) of this subsection. Patient information may be | 5 | | provided by the health care professional or a | 6 | | community-based organization, substance use disorder | 7 | | program, or other organization with which the health care | 8 | | professional establishes a written agreement that includes | 9 | | a description of how the organization will provide patient | 10 | | information, how employees or volunteers providing | 11 | | information will be trained, and standards for documenting | 12 | | the provision of patient information to patients. | 13 | | Provision of patient information shall be documented in | 14 | | the patient's medical record or through similar means as | 15 | | determined by agreement between the health care | 16 | | professional and the organization. The Department, in | 17 | | consultation with statewide organizations representing | 18 | | physicians, pharmacists, advanced practice registered | 19 | | nurses, physician assistants, substance use disorder | 20 | | programs, and other interested groups, shall develop and | 21 | | disseminate to health care professionals, community-based | 22 | | organizations, substance use disorder programs, and other | 23 | | organizations training materials in video, electronic, or | 24 | | other formats to facilitate the provision of such patient | 25 | | information. | 26 | | (4) For the purposes of this subsection: |
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| 1 | | "Opioid antagonist" means a drug that binds to opioid | 2 | | receptors and blocks or inhibits the effect of opioids | 3 | | acting on those receptors, including, but not limited to, | 4 | | naloxone hydrochloride or any other similarly acting drug | 5 | | approved by the U.S. Food and Drug Administration. | 6 | | "Health care professional" means a physician licensed | 7 | | to practice medicine in all its branches, a licensed | 8 | | physician assistant with prescriptive authority, a | 9 | | licensed advanced practice registered nurse with | 10 | | prescriptive authority, an advanced practice registered | 11 | | nurse or physician assistant who practices in a hospital, | 12 | | hospital affiliate, or ambulatory surgical treatment | 13 | | center and possesses appropriate clinical privileges in | 14 | | accordance with the Nurse Practice Act, or a pharmacist | 15 | | licensed to practice pharmacy under the Pharmacy Practice | 16 | | Act. | 17 | | "Patient" includes a person who is not at risk of | 18 | | opioid overdose but who, in the judgment of the physician, | 19 | | advanced practice registered nurse, or physician | 20 | | assistant, may be in a position to assist another | 21 | | individual during an overdose and who has received patient | 22 | | information as required in paragraph (2) of this | 23 | | subsection on the indications for and administration of an | 24 | | opioid antagonist. | 25 | | "Patient information" includes information provided to | 26 | | the patient on drug overdose prevention and recognition; |
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| 1 | | how to perform rescue breathing and resuscitation; opioid | 2 | | antagonist dosage and administration; the importance of | 3 | | calling 911; care for the overdose victim after | 4 | | administration of the overdose antagonist; and other | 5 | | issues as necessary.
| 6 | | (e) Drug overdose response policy. | 7 | | (1) Every State and local government agency that | 8 | | employs a law enforcement officer or fireman as those | 9 | | terms are defined in the Line of Duty Compensation Act | 10 | | must possess opioid antagonists and must establish a | 11 | | policy to control the acquisition, storage, | 12 | | transportation, and administration of such opioid | 13 | | antagonists and to provide training in the administration | 14 | | of opioid antagonists. A State or local government agency | 15 | | that employs a fireman as defined in the Line of Duty | 16 | | Compensation Act but does not respond to emergency medical | 17 | | calls or provide medical services shall be exempt from | 18 | | this subsection. | 19 | | (2) Every publicly or privately owned ambulance, | 20 | | special emergency medical services vehicle, non-transport | 21 | | vehicle, or ambulance assist vehicle, as described in the | 22 | | Emergency Medical Services (EMS) Systems Act, that | 23 | | responds to requests for emergency services or transports | 24 | | patients between hospitals in emergency situations must | 25 | | possess opioid antagonists. | 26 | | (3) Entities that are required under paragraphs (1) |
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| 1 | | and (2) to possess opioid antagonists may also apply to | 2 | | the Department for a grant to fund the acquisition of | 3 | | opioid antagonists and training programs on the | 4 | | administration of opioid antagonists. | 5 | | (Source: P.A. 100-201, eff. 8-18-17; 100-513, eff. 1-1-18; | 6 | | 100-759, eff. 1-1-19; 101-356, eff. 8-9-19.)
| 7 | | (20 ILCS 301/20-10)
| 8 | | Sec. 20-10. Screening, Brief Intervention, and Referral to | 9 | | Treatment. As used in this Section, "SBIRT" means a | 10 | | comprehensive, integrated, public health approach to the | 11 | | delivery of early intervention and treatment
services for | 12 | | persons who are at risk of developing substance use disorders | 13 | | or have substance use disorders including, but not limited to, | 14 | | an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT | 15 | | services include all of the following: | 16 | | (1) Screening to quickly assess the severity of | 17 | | substance use and to identify the appropriate level of | 18 | | treatment. | 19 | | (2) Brief intervention focused on increasing insight | 20 | | and awareness regarding substance use and motivation | 21 | | toward behavioral change. | 22 | | (3) Referral to treatment provided to those identified | 23 | | as needing more extensive treatment with access to | 24 | | specialty care. | 25 | | SBIRT services may include, but are not limited to, the |
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| 1 | | following settings and programs: primary care centers, | 2 | | hospital emergency rooms, hospital in-patient units,
trauma | 3 | | centers, community behavioral health programs, and other | 4 | | community settings that provide opportunities for early | 5 | | intervention with at-risk substance users before more severe
| 6 | | consequences occur. | 7 | | (a) As used in this Section, "SBIRT" means the | 8 | | identification of individuals, within primary care settings, | 9 | | who need substance use disorder treatment. Primary care | 10 | | providers will screen and, based on the results of the screen, | 11 | | deliver a brief intervention or make referral to a licensed | 12 | | treatment provider as appropriate. SBIRT is not a licensed | 13 | | category of service. | 14 | | (b) The Department may develop policy or best practice | 15 | | guidelines for identification of at-risk individuals through | 16 | | SBIRT and contract or billing requirements for SBIRT.
| 17 | | (Source: P.A. 100-759, eff. 1-1-19 .)
| 18 | | Section 10. The Illinois Public Aid Code is amended by | 19 | | changing Section 5-5 and by adding Section 5-41 as follows:
| 20 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 21 | | Sec. 5-5. Medical services. The Illinois Department, by | 22 | | rule, shall
determine the quantity and quality of and the rate | 23 | | of reimbursement for the
medical assistance for which
payment | 24 | | will be authorized, and the medical services to be provided,
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| 1 | | which may include all or part of the following: (1) inpatient | 2 | | hospital
services; (2) outpatient hospital services; (3) other | 3 | | laboratory and
X-ray services; (4) skilled nursing home | 4 | | services; (5) physicians'
services whether furnished in the | 5 | | office, the patient's home, a
hospital, a skilled nursing | 6 | | home, or elsewhere; (6) medical care, or any
other type of | 7 | | remedial care furnished by licensed practitioners; (7)
home | 8 | | health care services; (8) private duty nursing service; (9) | 9 | | clinic
services; (10) dental services, including prevention | 10 | | and treatment of periodontal disease and dental caries disease | 11 | | for pregnant women, provided by an individual licensed to | 12 | | practice dentistry or dental surgery; for purposes of this | 13 | | item (10), "dental services" means diagnostic, preventive, or | 14 | | corrective procedures provided by or under the supervision of | 15 | | a dentist in the practice of his or her profession; (11) | 16 | | physical therapy and related
services; (12) prescribed drugs, | 17 | | dentures, and prosthetic devices; and
eyeglasses prescribed by | 18 | | a physician skilled in the diseases of the eye,
or by an | 19 | | optometrist, whichever the person may select; (13) other
| 20 | | diagnostic, screening, preventive, and rehabilitative | 21 | | services, including to ensure that the individual's need for | 22 | | intervention or treatment of mental disorders or substance use | 23 | | disorders or co-occurring mental health and substance use | 24 | | disorders is determined using a uniform screening, assessment, | 25 | | and evaluation process inclusive of criteria, for children and | 26 | | adults; for purposes of this item (13), a uniform screening, |
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| 1 | | assessment, and evaluation process refers to a process that | 2 | | includes an appropriate evaluation and, as warranted, a | 3 | | referral; "uniform" does not mean the use of a singular | 4 | | instrument, tool, or process that all must utilize; (14)
| 5 | | transportation and such other expenses as may be necessary; | 6 | | (15) medical
treatment of sexual assault survivors, as defined | 7 | | in
Section 1a of the Sexual Assault Survivors Emergency | 8 | | Treatment Act, for
injuries sustained as a result of the | 9 | | sexual assault, including
examinations and laboratory tests to | 10 | | discover evidence which may be used in
criminal proceedings | 11 | | arising from the sexual assault; (16) the
diagnosis and | 12 | | treatment of sickle cell anemia; and (17)
any other medical | 13 | | care, and any other type of remedial care recognized
under the | 14 | | laws of this State. The term "any other type of remedial care" | 15 | | shall
include nursing care and nursing home service for | 16 | | persons who rely on
treatment by spiritual means alone through | 17 | | prayer for healing.
| 18 | | Notwithstanding any other provision of this Section, a | 19 | | comprehensive
tobacco use cessation program that includes | 20 | | purchasing prescription drugs or
prescription medical devices | 21 | | approved by the Food and Drug Administration shall
be covered | 22 | | under the medical assistance
program under this Article for | 23 | | persons who are otherwise eligible for
assistance under this | 24 | | Article.
| 25 | | Notwithstanding any other provision of this Code, | 26 | | reproductive health care that is otherwise legal in Illinois |
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| 1 | | shall be covered under the medical assistance program for | 2 | | persons who are otherwise eligible for medical assistance | 3 | | under this Article. | 4 | | Notwithstanding any other provision of this Code, the | 5 | | Illinois
Department may not require, as a condition of payment | 6 | | for any laboratory
test authorized under this Article, that a | 7 | | physician's handwritten signature
appear on the laboratory | 8 | | test order form. The Illinois Department may,
however, impose | 9 | | other appropriate requirements regarding laboratory test
order | 10 | | documentation.
| 11 | | Upon receipt of federal approval of an amendment to the | 12 | | Illinois Title XIX State Plan for this purpose, the Department | 13 | | shall authorize the Chicago Public Schools (CPS) to procure a | 14 | | vendor or vendors to manufacture eyeglasses for individuals | 15 | | enrolled in a school within the CPS system. CPS shall ensure | 16 | | that its vendor or vendors are enrolled as providers in the | 17 | | medical assistance program and in any capitated Medicaid | 18 | | managed care entity (MCE) serving individuals enrolled in a | 19 | | school within the CPS system. Under any contract procured | 20 | | under this provision, the vendor or vendors must serve only | 21 | | individuals enrolled in a school within the CPS system. Claims | 22 | | for services provided by CPS's vendor or vendors to recipients | 23 | | of benefits in the medical assistance program under this Code, | 24 | | the Children's Health Insurance Program, or the Covering ALL | 25 | | KIDS Health Insurance Program shall be submitted to the | 26 | | Department or the MCE in which the individual is enrolled for |
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| 1 | | payment and shall be reimbursed at the Department's or the | 2 | | MCE's established rates or rate methodologies for eyeglasses. | 3 | | On and after July 1, 2012, the Department of Healthcare | 4 | | and Family Services may provide the following services to
| 5 | | persons
eligible for assistance under this Article who are | 6 | | participating in
education, training or employment programs | 7 | | operated by the Department of Human
Services as successor to | 8 | | the Department of Public Aid:
| 9 | | (1) dental services provided by or under the | 10 | | supervision of a dentist; and
| 11 | | (2) eyeglasses prescribed by a physician skilled in | 12 | | the diseases of the
eye, or by an optometrist, whichever | 13 | | the person may select.
| 14 | | On and after July 1, 2018, the Department of Healthcare | 15 | | and Family Services shall provide dental services to any adult | 16 | | who is otherwise eligible for assistance under the medical | 17 | | assistance program. As used in this paragraph, "dental | 18 | | services" means diagnostic, preventative, restorative, or | 19 | | corrective procedures, including procedures and services for | 20 | | the prevention and treatment of periodontal disease and dental | 21 | | caries disease, provided by an individual who is licensed to | 22 | | practice dentistry or dental surgery or who is under the | 23 | | supervision of a dentist in the practice of his or her | 24 | | profession. | 25 | | On and after July 1, 2018, targeted dental services, as | 26 | | set forth in Exhibit D of the Consent Decree entered by the |
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| 1 | | United States District Court for the Northern District of | 2 | | Illinois, Eastern Division, in the matter of Memisovski v. | 3 | | Maram, Case No. 92 C 1982, that are provided to adults under | 4 | | the medical assistance program shall be established at no less | 5 | | than the rates set forth in the "New Rate" column in Exhibit D | 6 | | of the Consent Decree for targeted dental services that are | 7 | | provided to persons under the age of 18 under the medical | 8 | | assistance program. | 9 | | Notwithstanding any other provision of this Code and | 10 | | subject to federal approval, the Department may adopt rules to | 11 | | allow a dentist who is volunteering his or her service at no | 12 | | cost to render dental services through an enrolled | 13 | | not-for-profit health clinic without the dentist personally | 14 | | enrolling as a participating provider in the medical | 15 | | assistance program. A not-for-profit health clinic shall | 16 | | include a public health clinic or Federally Qualified Health | 17 | | Center or other enrolled provider, as determined by the | 18 | | Department, through which dental services covered under this | 19 | | Section are performed. The Department shall establish a | 20 | | process for payment of claims for reimbursement for covered | 21 | | dental services rendered under this provision. | 22 | | The Illinois Department, by rule, may distinguish and | 23 | | classify the
medical services to be provided only in | 24 | | accordance with the classes of
persons designated in Section | 25 | | 5-2.
| 26 | | The Department of Healthcare and Family Services must |
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| 1 | | provide coverage and reimbursement for amino acid-based | 2 | | elemental formulas, regardless of delivery method, for the | 3 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 4 | | short bowel syndrome when the prescribing physician has issued | 5 | | a written order stating that the amino acid-based elemental | 6 | | formula is medically necessary.
| 7 | | The Illinois Department shall authorize the provision of, | 8 | | and shall
authorize payment for, screening by low-dose | 9 | | mammography for the presence of
occult breast cancer for women | 10 | | 35 years of age or older who are eligible
for medical | 11 | | assistance under this Article, as follows: | 12 | | (A) A baseline
mammogram for women 35 to 39 years of | 13 | | age.
| 14 | | (B) An annual mammogram for women 40 years of age or | 15 | | older. | 16 | | (C) A mammogram at the age and intervals considered | 17 | | medically necessary by the woman's health care provider | 18 | | for women under 40 years of age and having a family history | 19 | | of breast cancer, prior personal history of breast cancer, | 20 | | positive genetic testing, or other risk factors. | 21 | | (D) A comprehensive ultrasound screening and MRI of an | 22 | | entire breast or breasts if a mammogram demonstrates | 23 | | heterogeneous or dense breast tissue or when medically | 24 | | necessary as determined by a physician licensed to | 25 | | practice medicine in all of its branches. | 26 | | (E) A screening MRI when medically necessary, as |
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| 1 | | determined by a physician licensed to practice medicine in | 2 | | all of its branches. | 3 | | (F) A diagnostic mammogram when medically necessary, | 4 | | as determined by a physician licensed to practice medicine | 5 | | in all its branches, advanced practice registered nurse, | 6 | | or physician assistant. | 7 | | The Department shall not impose a deductible, coinsurance, | 8 | | copayment, or any other cost-sharing requirement on the | 9 | | coverage provided under this paragraph; except that this | 10 | | sentence does not apply to coverage of diagnostic mammograms | 11 | | to the extent such coverage would disqualify a high-deductible | 12 | | health plan from eligibility for a health savings account | 13 | | pursuant to Section 223 of the Internal Revenue Code (26 | 14 | | U.S.C. 223). | 15 | | All screenings
shall
include a physical breast exam, | 16 | | instruction on self-examination and
information regarding the | 17 | | frequency of self-examination and its value as a
preventative | 18 | | tool. | 19 | | For purposes of this Section: | 20 | | "Diagnostic
mammogram" means a mammogram obtained using | 21 | | diagnostic mammography. | 22 | | "Diagnostic
mammography" means a method of screening that | 23 | | is designed to
evaluate an abnormality in a breast, including | 24 | | an abnormality seen
or suspected on a screening mammogram or a | 25 | | subjective or objective
abnormality otherwise detected in the | 26 | | breast. |
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| 1 | | "Low-dose mammography" means
the x-ray examination of the | 2 | | breast using equipment dedicated specifically
for mammography, | 3 | | including the x-ray tube, filter, compression device,
and | 4 | | image receptor, with an average radiation exposure delivery
of | 5 | | less than one rad per breast for 2 views of an average size | 6 | | breast.
The term also includes digital mammography and | 7 | | includes breast tomosynthesis. | 8 | | "Breast tomosynthesis" means a radiologic procedure that | 9 | | involves the acquisition of projection images over the | 10 | | stationary breast to produce cross-sectional digital | 11 | | three-dimensional images of the breast. | 12 | | If, at any time, the Secretary of the United States | 13 | | Department of Health and Human Services, or its successor | 14 | | agency, promulgates rules or regulations to be published in | 15 | | the Federal Register or publishes a comment in the Federal | 16 | | Register or issues an opinion, guidance, or other action that | 17 | | would require the State, pursuant to any provision of the | 18 | | Patient Protection and Affordable Care Act (Public Law | 19 | | 111-148), including, but not limited to, 42 U.S.C. | 20 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 21 | | of any coverage for breast tomosynthesis outlined in this | 22 | | paragraph, then the requirement that an insurer cover breast | 23 | | tomosynthesis is inoperative other than any such coverage | 24 | | authorized under Section 1902 of the Social Security Act, 42 | 25 | | U.S.C. 1396a, and the State shall not assume any obligation | 26 | | for the cost of coverage for breast tomosynthesis set forth in |
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| 1 | | this paragraph.
| 2 | | On and after January 1, 2016, the Department shall ensure | 3 | | that all networks of care for adult clients of the Department | 4 | | include access to at least one breast imaging Center of | 5 | | Imaging Excellence as certified by the American College of | 6 | | Radiology. | 7 | | On and after January 1, 2012, providers participating in a | 8 | | quality improvement program approved by the Department shall | 9 | | be reimbursed for screening and diagnostic mammography at the | 10 | | same rate as the Medicare program's rates, including the | 11 | | increased reimbursement for digital mammography. | 12 | | The Department shall convene an expert panel including | 13 | | representatives of hospitals, free-standing mammography | 14 | | facilities, and doctors, including radiologists, to establish | 15 | | quality standards for mammography. | 16 | | On and after January 1, 2017, providers participating in a | 17 | | breast cancer treatment quality improvement program approved | 18 | | by the Department shall be reimbursed for breast cancer | 19 | | treatment at a rate that is no lower than 95% of the Medicare | 20 | | program's rates for the data elements included in the breast | 21 | | cancer treatment quality program. | 22 | | The Department shall convene an expert panel, including | 23 | | representatives of hospitals, free-standing breast cancer | 24 | | treatment centers, breast cancer quality organizations, and | 25 | | doctors, including breast surgeons, reconstructive breast | 26 | | surgeons, oncologists, and primary care providers to establish |
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| 1 | | quality standards for breast cancer treatment. | 2 | | Subject to federal approval, the Department shall | 3 | | establish a rate methodology for mammography at federally | 4 | | qualified health centers and other encounter-rate clinics. | 5 | | These clinics or centers may also collaborate with other | 6 | | hospital-based mammography facilities. By January 1, 2016, the | 7 | | Department shall report to the General Assembly on the status | 8 | | of the provision set forth in this paragraph. | 9 | | The Department shall establish a methodology to remind | 10 | | women who are age-appropriate for screening mammography, but | 11 | | who have not received a mammogram within the previous 18 | 12 | | months, of the importance and benefit of screening | 13 | | mammography. The Department shall work with experts in breast | 14 | | cancer outreach and patient navigation to optimize these | 15 | | reminders and shall establish a methodology for evaluating | 16 | | their effectiveness and modifying the methodology based on the | 17 | | evaluation. | 18 | | The Department shall establish a performance goal for | 19 | | primary care providers with respect to their female patients | 20 | | over age 40 receiving an annual mammogram. This performance | 21 | | goal shall be used to provide additional reimbursement in the | 22 | | form of a quality performance bonus to primary care providers | 23 | | who meet that goal. | 24 | | The Department shall devise a means of case-managing or | 25 | | patient navigation for beneficiaries diagnosed with breast | 26 | | cancer. This program shall initially operate as a pilot |
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| 1 | | program in areas of the State with the highest incidence of | 2 | | mortality related to breast cancer. At least one pilot program | 3 | | site shall be in the metropolitan Chicago area and at least one | 4 | | site shall be outside the metropolitan Chicago area. On or | 5 | | after July 1, 2016, the pilot program shall be expanded to | 6 | | include one site in western Illinois, one site in southern | 7 | | Illinois, one site in central Illinois, and 4 sites within | 8 | | metropolitan Chicago. An evaluation of the pilot program shall | 9 | | be carried out measuring health outcomes and cost of care for | 10 | | those served by the pilot program compared to similarly | 11 | | situated patients who are not served by the pilot program. | 12 | | The Department shall require all networks of care to | 13 | | develop a means either internally or by contract with experts | 14 | | in navigation and community outreach to navigate cancer | 15 | | patients to comprehensive care in a timely fashion. The | 16 | | Department shall require all networks of care to include | 17 | | access for patients diagnosed with cancer to at least one | 18 | | academic commission on cancer-accredited cancer program as an | 19 | | in-network covered benefit. | 20 | | Any medical or health care provider shall immediately | 21 | | recommend, to
any pregnant woman who is being provided | 22 | | prenatal services and is suspected
of having a substance use | 23 | | disorder as defined in the Substance Use Disorder Act, | 24 | | referral to a local substance use disorder treatment program | 25 | | licensed by the Department of Human Services or to a licensed
| 26 | | hospital which provides substance abuse treatment services. |
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| 1 | | The Department of Healthcare and Family Services
shall assure | 2 | | coverage for the cost of treatment of the drug abuse or
| 3 | | addiction for pregnant recipients in accordance with the | 4 | | Illinois Medicaid
Program in conjunction with the Department | 5 | | of Human Services.
| 6 | | All medical providers providing medical assistance to | 7 | | pregnant women
under this Code shall receive information from | 8 | | the Department on the
availability of services under any
| 9 | | program providing case management services for addicted women,
| 10 | | including information on appropriate referrals for other | 11 | | social services
that may be needed by addicted women in | 12 | | addition to treatment for addiction.
| 13 | | The Illinois Department, in cooperation with the | 14 | | Departments of Human
Services (as successor to the Department | 15 | | of Alcoholism and Substance
Abuse) and Public Health, through | 16 | | a public awareness campaign, may
provide information | 17 | | concerning treatment for alcoholism and drug abuse and
| 18 | | addiction, prenatal health care, and other pertinent programs | 19 | | directed at
reducing the number of drug-affected infants born | 20 | | to recipients of medical
assistance.
| 21 | | Neither the Department of Healthcare and Family Services | 22 | | nor the Department of Human
Services shall sanction the | 23 | | recipient solely on the basis of
her substance abuse.
| 24 | | The Illinois Department shall establish such regulations | 25 | | governing
the dispensing of health services under this Article | 26 | | as it shall deem
appropriate. The Department
should
seek the |
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| 1 | | advice of formal professional advisory committees appointed by
| 2 | | the Director of the Illinois Department for the purpose of | 3 | | providing regular
advice on policy and administrative matters, | 4 | | information dissemination and
educational activities for | 5 | | medical and health care providers, and
consistency in | 6 | | procedures to the Illinois Department.
| 7 | | The Illinois Department may develop and contract with | 8 | | Partnerships of
medical providers to arrange medical services | 9 | | for persons eligible under
Section 5-2 of this Code. | 10 | | Implementation of this Section may be by
demonstration | 11 | | projects in certain geographic areas. The Partnership shall
be | 12 | | represented by a sponsor organization. The Department, by | 13 | | rule, shall
develop qualifications for sponsors of | 14 | | Partnerships. Nothing in this
Section shall be construed to | 15 | | require that the sponsor organization be a
medical | 16 | | organization.
| 17 | | The sponsor must negotiate formal written contracts with | 18 | | medical
providers for physician services, inpatient and | 19 | | outpatient hospital care,
home health services, treatment for | 20 | | alcoholism and substance abuse, and
other services determined | 21 | | necessary by the Illinois Department by rule for
delivery by | 22 | | Partnerships. Physician services must include prenatal and
| 23 | | obstetrical care. The Illinois Department shall reimburse | 24 | | medical services
delivered by Partnership providers to clients | 25 | | in target areas according to
provisions of this Article and | 26 | | the Illinois Health Finance Reform Act,
except that:
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| 1 | | (1) Physicians participating in a Partnership and | 2 | | providing certain
services, which shall be determined by | 3 | | the Illinois Department, to persons
in areas covered by | 4 | | the Partnership may receive an additional surcharge
for | 5 | | such services.
| 6 | | (2) The Department may elect to consider and negotiate | 7 | | financial
incentives to encourage the development of | 8 | | Partnerships and the efficient
delivery of medical care.
| 9 | | (3) Persons receiving medical services through | 10 | | Partnerships may receive
medical and case management | 11 | | services above the level usually offered
through the | 12 | | medical assistance program.
| 13 | | Medical providers shall be required to meet certain | 14 | | qualifications to
participate in Partnerships to ensure the | 15 | | delivery of high quality medical
services. These | 16 | | qualifications shall be determined by rule of the Illinois
| 17 | | Department and may be higher than qualifications for | 18 | | participation in the
medical assistance program. Partnership | 19 | | sponsors may prescribe reasonable
additional qualifications | 20 | | for participation by medical providers, only with
the prior | 21 | | written approval of the Illinois Department.
| 22 | | Nothing in this Section shall limit the free choice of | 23 | | practitioners,
hospitals, and other providers of medical | 24 | | services by clients.
In order to ensure patient freedom of | 25 | | choice, the Illinois Department shall
immediately promulgate | 26 | | all rules and take all other necessary actions so that
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| 1 | | provided services may be accessed from therapeutically | 2 | | certified optometrists
to the full extent of the Illinois | 3 | | Optometric Practice Act of 1987 without
discriminating between | 4 | | service providers.
| 5 | | The Department shall apply for a waiver from the United | 6 | | States Health
Care Financing Administration to allow for the | 7 | | implementation of
Partnerships under this Section.
| 8 | | The Illinois Department shall require health care | 9 | | providers to maintain
records that document the medical care | 10 | | and services provided to recipients
of Medical Assistance | 11 | | under this Article. Such records must be retained for a period | 12 | | of not less than 6 years from the date of service or as | 13 | | provided by applicable State law, whichever period is longer, | 14 | | except that if an audit is initiated within the required | 15 | | retention period then the records must be retained until the | 16 | | audit is completed and every exception is resolved. The | 17 | | Illinois Department shall
require health care providers to | 18 | | make available, when authorized by the
patient, in writing, | 19 | | the medical records in a timely fashion to other
health care | 20 | | providers who are treating or serving persons eligible for
| 21 | | Medical Assistance under this Article. All dispensers of | 22 | | medical services
shall be required to maintain and retain | 23 | | business and professional records
sufficient to fully and | 24 | | accurately document the nature, scope, details and
receipt of | 25 | | the health care provided to persons eligible for medical
| 26 | | assistance under this Code, in accordance with regulations |
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| 1 | | promulgated by
the Illinois Department. The rules and | 2 | | regulations shall require that proof
of the receipt of | 3 | | prescription drugs, dentures, prosthetic devices and
| 4 | | eyeglasses by eligible persons under this Section accompany | 5 | | each claim
for reimbursement submitted by the dispenser of | 6 | | such medical services.
No such claims for reimbursement shall | 7 | | be approved for payment by the Illinois
Department without | 8 | | such proof of receipt, unless the Illinois Department
shall | 9 | | have put into effect and shall be operating a system of | 10 | | post-payment
audit and review which shall, on a sampling | 11 | | basis, be deemed adequate by
the Illinois Department to assure | 12 | | that such drugs, dentures, prosthetic
devices and eyeglasses | 13 | | for which payment is being made are actually being
received by | 14 | | eligible recipients. Within 90 days after September 16, 1984 | 15 | | (the effective date of Public Act 83-1439), the Illinois | 16 | | Department shall establish a
current list of acquisition costs | 17 | | for all prosthetic devices and any
other items recognized as | 18 | | medical equipment and supplies reimbursable under
this Article | 19 | | and shall update such list on a quarterly basis, except that
| 20 | | the acquisition costs of all prescription drugs shall be | 21 | | updated no
less frequently than every 30 days as required by | 22 | | Section 5-5.12.
| 23 | | Notwithstanding any other law to the contrary, the | 24 | | Illinois Department shall, within 365 days after July 22, 2013 | 25 | | (the effective date of Public Act 98-104), establish | 26 | | procedures to permit skilled care facilities licensed under |
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| 1 | | the Nursing Home Care Act to submit monthly billing claims for | 2 | | reimbursement purposes. Following development of these | 3 | | procedures, the Department shall, by July 1, 2016, test the | 4 | | viability of the new system and implement any necessary | 5 | | operational or structural changes to its information | 6 | | technology platforms in order to allow for the direct | 7 | | acceptance and payment of nursing home claims. | 8 | | Notwithstanding any other law to the contrary, the | 9 | | Illinois Department shall, within 365 days after August 15, | 10 | | 2014 (the effective date of Public Act 98-963), establish | 11 | | procedures to permit ID/DD facilities licensed under the ID/DD | 12 | | Community Care Act and MC/DD facilities licensed under the | 13 | | MC/DD Act to submit monthly billing claims for reimbursement | 14 | | purposes. Following development of these procedures, the | 15 | | Department shall have an additional 365 days to test the | 16 | | viability of the new system and to ensure that any necessary | 17 | | operational or structural changes to its information | 18 | | technology platforms are implemented. | 19 | | The Illinois Department shall require all dispensers of | 20 | | medical
services, other than an individual practitioner or | 21 | | group of practitioners,
desiring to participate in the Medical | 22 | | Assistance program
established under this Article to disclose | 23 | | all financial, beneficial,
ownership, equity, surety or other | 24 | | interests in any and all firms,
corporations, partnerships, | 25 | | associations, business enterprises, joint
ventures, agencies, | 26 | | institutions or other legal entities providing any
form of |
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| 1 | | health care services in this State under this Article.
| 2 | | The Illinois Department may require that all dispensers of | 3 | | medical
services desiring to participate in the medical | 4 | | assistance program
established under this Article disclose, | 5 | | under such terms and conditions as
the Illinois Department may | 6 | | by rule establish, all inquiries from clients
and attorneys | 7 | | regarding medical bills paid by the Illinois Department, which
| 8 | | inquiries could indicate potential existence of claims or | 9 | | liens for the
Illinois Department.
| 10 | | Enrollment of a vendor
shall be
subject to a provisional | 11 | | period and shall be conditional for one year. During the | 12 | | period of conditional enrollment, the Department may
terminate | 13 | | the vendor's eligibility to participate in, or may disenroll | 14 | | the vendor from, the medical assistance
program without cause. | 15 | | Unless otherwise specified, such termination of eligibility or | 16 | | disenrollment is not subject to the
Department's hearing | 17 | | process.
However, a disenrolled vendor may reapply without | 18 | | penalty.
| 19 | | The Department has the discretion to limit the conditional | 20 | | enrollment period for vendors based upon category of risk of | 21 | | the vendor. | 22 | | Prior to enrollment and during the conditional enrollment | 23 | | period in the medical assistance program, all vendors shall be | 24 | | subject to enhanced oversight, screening, and review based on | 25 | | the risk of fraud, waste, and abuse that is posed by the | 26 | | category of risk of the vendor. The Illinois Department shall |
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| 1 | | establish the procedures for oversight, screening, and review, | 2 | | which may include, but need not be limited to: criminal and | 3 | | financial background checks; fingerprinting; license, | 4 | | certification, and authorization verifications; unscheduled or | 5 | | unannounced site visits; database checks; prepayment audit | 6 | | reviews; audits; payment caps; payment suspensions; and other | 7 | | screening as required by federal or State law. | 8 | | The Department shall define or specify the following: (i) | 9 | | by provider notice, the "category of risk of the vendor" for | 10 | | each type of vendor, which shall take into account the level of | 11 | | screening applicable to a particular category of vendor under | 12 | | federal law and regulations; (ii) by rule or provider notice, | 13 | | the maximum length of the conditional enrollment period for | 14 | | each category of risk of the vendor; and (iii) by rule, the | 15 | | hearing rights, if any, afforded to a vendor in each category | 16 | | of risk of the vendor that is terminated or disenrolled during | 17 | | the conditional enrollment period. | 18 | | To be eligible for payment consideration, a vendor's | 19 | | payment claim or bill, either as an initial claim or as a | 20 | | resubmitted claim following prior rejection, must be received | 21 | | by the Illinois Department, or its fiscal intermediary, no | 22 | | later than 180 days after the latest date on the claim on which | 23 | | medical goods or services were provided, with the following | 24 | | exceptions: | 25 | | (1) In the case of a provider whose enrollment is in | 26 | | process by the Illinois Department, the 180-day period |
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| 1 | | shall not begin until the date on the written notice from | 2 | | the Illinois Department that the provider enrollment is | 3 | | complete. | 4 | | (2) In the case of errors attributable to the Illinois | 5 | | Department or any of its claims processing intermediaries | 6 | | which result in an inability to receive, process, or | 7 | | adjudicate a claim, the 180-day period shall not begin | 8 | | until the provider has been notified of the error. | 9 | | (3) In the case of a provider for whom the Illinois | 10 | | Department initiates the monthly billing process. | 11 | | (4) In the case of a provider operated by a unit of | 12 | | local government with a population exceeding 3,000,000 | 13 | | when local government funds finance federal participation | 14 | | for claims payments. | 15 | | For claims for services rendered during a period for which | 16 | | a recipient received retroactive eligibility, claims must be | 17 | | filed within 180 days after the Department determines the | 18 | | applicant is eligible. For claims for which the Illinois | 19 | | Department is not the primary payer, claims must be submitted | 20 | | to the Illinois Department within 180 days after the final | 21 | | adjudication by the primary payer. | 22 | | In the case of long term care facilities, within 45 | 23 | | calendar days of receipt by the facility of required | 24 | | prescreening information, new admissions with associated | 25 | | admission documents shall be submitted through the Medical | 26 | | Electronic Data Interchange (MEDI) or the Recipient |
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| 1 | | Eligibility Verification (REV) System or shall be submitted | 2 | | directly to the Department of Human Services using required | 3 | | admission forms. Effective September
1, 2014, admission | 4 | | documents, including all prescreening
information, must be | 5 | | submitted through MEDI or REV. Confirmation numbers assigned | 6 | | to an accepted transaction shall be retained by a facility to | 7 | | verify timely submittal. Once an admission transaction has | 8 | | been completed, all resubmitted claims following prior | 9 | | rejection are subject to receipt no later than 180 days after | 10 | | the admission transaction has been completed. | 11 | | Claims that are not submitted and received in compliance | 12 | | with the foregoing requirements shall not be eligible for | 13 | | payment under the medical assistance program, and the State | 14 | | shall have no liability for payment of those claims. | 15 | | To the extent consistent with applicable information and | 16 | | privacy, security, and disclosure laws, State and federal | 17 | | agencies and departments shall provide the Illinois Department | 18 | | access to confidential and other information and data | 19 | | necessary to perform eligibility and payment verifications and | 20 | | other Illinois Department functions. This includes, but is not | 21 | | limited to: information pertaining to licensure; | 22 | | certification; earnings; immigration status; citizenship; wage | 23 | | reporting; unearned and earned income; pension income; | 24 | | employment; supplemental security income; social security | 25 | | numbers; National Provider Identifier (NPI) numbers; the | 26 | | National Practitioner Data Bank (NPDB); program and agency |
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| 1 | | exclusions; taxpayer identification numbers; tax delinquency; | 2 | | corporate information; and death records. | 3 | | The Illinois Department shall enter into agreements with | 4 | | State agencies and departments, and is authorized to enter | 5 | | into agreements with federal agencies and departments, under | 6 | | which such agencies and departments shall share data necessary | 7 | | for medical assistance program integrity functions and | 8 | | oversight. The Illinois Department shall develop, in | 9 | | cooperation with other State departments and agencies, and in | 10 | | compliance with applicable federal laws and regulations, | 11 | | appropriate and effective methods to share such data. At a | 12 | | minimum, and to the extent necessary to provide data sharing, | 13 | | the Illinois Department shall enter into agreements with State | 14 | | agencies and departments, and is authorized to enter into | 15 | | agreements with federal agencies and departments, including , | 16 | | but not limited to: the Secretary of State; the Department of | 17 | | Revenue; the Department of Public Health; the Department of | 18 | | Human Services; and the Department of Financial and | 19 | | Professional Regulation. | 20 | | Beginning in fiscal year 2013, the Illinois Department | 21 | | shall set forth a request for information to identify the | 22 | | benefits of a pre-payment, post-adjudication, and post-edit | 23 | | claims system with the goals of streamlining claims processing | 24 | | and provider reimbursement, reducing the number of pending or | 25 | | rejected claims, and helping to ensure a more transparent | 26 | | adjudication process through the utilization of: (i) provider |
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| 1 | | data verification and provider screening technology; and (ii) | 2 | | clinical code editing; and (iii) pre-pay, pre- or | 3 | | post-adjudicated predictive modeling with an integrated case | 4 | | management system with link analysis. Such a request for | 5 | | information shall not be considered as a request for proposal | 6 | | or as an obligation on the part of the Illinois Department to | 7 | | take any action or acquire any products or services. | 8 | | The Illinois Department shall establish policies, | 9 | | procedures,
standards and criteria by rule for the | 10 | | acquisition, repair and replacement
of orthotic and prosthetic | 11 | | devices and durable medical equipment. Such
rules shall | 12 | | provide, but not be limited to, the following services: (1)
| 13 | | immediate repair or replacement of such devices by recipients; | 14 | | and (2) rental, lease, purchase or lease-purchase of
durable | 15 | | medical equipment in a cost-effective manner, taking into
| 16 | | consideration the recipient's medical prognosis, the extent of | 17 | | the
recipient's needs, and the requirements and costs for | 18 | | maintaining such
equipment. Subject to prior approval, such | 19 | | rules shall enable a recipient to temporarily acquire and
use | 20 | | alternative or substitute devices or equipment pending repairs | 21 | | or
replacements of any device or equipment previously | 22 | | authorized for such
recipient by the Department. | 23 | | Notwithstanding any provision of Section 5-5f to the contrary, | 24 | | the Department may, by rule, exempt certain replacement | 25 | | wheelchair parts from prior approval and, for wheelchairs, | 26 | | wheelchair parts, wheelchair accessories, and related seating |
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| 1 | | and positioning items, determine the wholesale price by | 2 | | methods other than actual acquisition costs. | 3 | | The Department shall require, by rule, all providers of | 4 | | durable medical equipment to be accredited by an accreditation | 5 | | organization approved by the federal Centers for Medicare and | 6 | | Medicaid Services and recognized by the Department in order to | 7 | | bill the Department for providing durable medical equipment to | 8 | | recipients. No later than 15 months after the effective date | 9 | | of the rule adopted pursuant to this paragraph, all providers | 10 | | must meet the accreditation requirement.
| 11 | | In order to promote environmental responsibility, meet the | 12 | | needs of recipients and enrollees, and achieve significant | 13 | | cost savings, the Department, or a managed care organization | 14 | | under contract with the Department, may provide recipients or | 15 | | managed care enrollees who have a prescription or Certificate | 16 | | of Medical Necessity access to refurbished durable medical | 17 | | equipment under this Section (excluding prosthetic and | 18 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 19 | | Pedorthics Practice Act and complex rehabilitation technology | 20 | | products and associated services) through the State's | 21 | | assistive technology program's reutilization program, using | 22 | | staff with the Assistive Technology Professional (ATP) | 23 | | Certification if the refurbished durable medical equipment: | 24 | | (i) is available; (ii) is less expensive, including shipping | 25 | | costs, than new durable medical equipment of the same type; | 26 | | (iii) is able to withstand at least 3 years of use; (iv) is |
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| 1 | | cleaned, disinfected, sterilized, and safe in accordance with | 2 | | federal Food and Drug Administration regulations and guidance | 3 | | governing the reprocessing of medical devices in health care | 4 | | settings; and (v) equally meets the needs of the recipient or | 5 | | enrollee. The reutilization program shall confirm that the | 6 | | recipient or enrollee is not already in receipt of same or | 7 | | similar equipment from another service provider, and that the | 8 | | refurbished durable medical equipment equally meets the needs | 9 | | of the recipient or enrollee. Nothing in this paragraph shall | 10 | | be construed to limit recipient or enrollee choice to obtain | 11 | | new durable medical equipment or place any additional prior | 12 | | authorization conditions on enrollees of managed care | 13 | | organizations. | 14 | | The Department shall execute, relative to the nursing home | 15 | | prescreening
project, written inter-agency agreements with the | 16 | | Department of Human
Services and the Department on Aging, to | 17 | | effect the following: (i) intake
procedures and common | 18 | | eligibility criteria for those persons who are receiving
| 19 | | non-institutional services; and (ii) the establishment and | 20 | | development of
non-institutional services in areas of the | 21 | | State where they are not currently
available or are | 22 | | undeveloped; and (iii) notwithstanding any other provision of | 23 | | law, subject to federal approval, on and after July 1, 2012, an | 24 | | increase in the determination of need (DON) scores from 29 to | 25 | | 37 for applicants for institutional and home and | 26 | | community-based long term care; if and only if federal |
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| 1 | | approval is not granted, the Department may, in conjunction | 2 | | with other affected agencies, implement utilization controls | 3 | | or changes in benefit packages to effectuate a similar savings | 4 | | amount for this population; and (iv) no later than July 1, | 5 | | 2013, minimum level of care eligibility criteria for | 6 | | institutional and home and community-based long term care; and | 7 | | (v) no later than October 1, 2013, establish procedures to | 8 | | permit long term care providers access to eligibility scores | 9 | | for individuals with an admission date who are seeking or | 10 | | receiving services from the long term care provider. In order | 11 | | to select the minimum level of care eligibility criteria, the | 12 | | Governor shall establish a workgroup that includes affected | 13 | | agency representatives and stakeholders representing the | 14 | | institutional and home and community-based long term care | 15 | | interests. This Section shall not restrict the Department from | 16 | | implementing lower level of care eligibility criteria for | 17 | | community-based services in circumstances where federal | 18 | | approval has been granted.
| 19 | | The Illinois Department shall develop and operate, in | 20 | | cooperation
with other State Departments and agencies and in | 21 | | compliance with
applicable federal laws and regulations, | 22 | | appropriate and effective
systems of health care evaluation | 23 | | and programs for monitoring of
utilization of health care | 24 | | services and facilities, as it affects
persons eligible for | 25 | | medical assistance under this Code.
| 26 | | The Illinois Department shall report annually to the |
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| 1 | | General Assembly,
no later than the second Friday in April of | 2 | | 1979 and each year
thereafter, in regard to:
| 3 | | (a) actual statistics and trends in utilization of | 4 | | medical services by
public aid recipients;
| 5 | | (b) actual statistics and trends in the provision of | 6 | | the various medical
services by medical vendors;
| 7 | | (c) current rate structures and proposed changes in | 8 | | those rate structures
for the various medical vendors; and
| 9 | | (d) efforts at utilization review and control by the | 10 | | Illinois Department.
| 11 | | The period covered by each report shall be the 3 years | 12 | | ending on the June
30 prior to the report. The report shall | 13 | | include suggested legislation
for consideration by the General | 14 | | Assembly. The requirement for reporting to the General | 15 | | Assembly shall be satisfied
by filing copies of the report as | 16 | | required by Section 3.1 of the General Assembly Organization | 17 | | Act, and filing such additional
copies
with the State | 18 | | Government Report Distribution Center for the General
Assembly | 19 | | as is required under paragraph (t) of Section 7 of the State
| 20 | | Library Act.
| 21 | | Rulemaking authority to implement Public Act 95-1045, if | 22 | | any, is conditioned on the rules being adopted in accordance | 23 | | with all provisions of the Illinois Administrative Procedure | 24 | | Act and all rules and procedures of the Joint Committee on | 25 | | Administrative Rules; any purported rule not so adopted, for | 26 | | whatever reason, is unauthorized. |
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| 1 | | On and after July 1, 2012, the Department shall reduce any | 2 | | rate of reimbursement for services or other payments or alter | 3 | | any methodologies authorized by this Code to reduce any rate | 4 | | of reimbursement for services or other payments in accordance | 5 | | with Section 5-5e. | 6 | | Because kidney transplantation can be an appropriate, | 7 | | cost-effective
alternative to renal dialysis when medically | 8 | | necessary and notwithstanding the provisions of Section 1-11 | 9 | | of this Code, beginning October 1, 2014, the Department shall | 10 | | cover kidney transplantation for noncitizens with end-stage | 11 | | renal disease who are not eligible for comprehensive medical | 12 | | benefits, who meet the residency requirements of Section 5-3 | 13 | | of this Code, and who would otherwise meet the financial | 14 | | requirements of the appropriate class of eligible persons | 15 | | under Section 5-2 of this Code. To qualify for coverage of | 16 | | kidney transplantation, such person must be receiving | 17 | | emergency renal dialysis services covered by the Department. | 18 | | Providers under this Section shall be prior approved and | 19 | | certified by the Department to perform kidney transplantation | 20 | | and the services under this Section shall be limited to | 21 | | services associated with kidney transplantation. | 22 | | Notwithstanding any other provision of this Code to the | 23 | | contrary, on or after July 1, 2015, all FDA approved forms of | 24 | | medication assisted treatment prescribed for the treatment of | 25 | | alcohol dependence or treatment of opioid dependence shall be | 26 | | covered under both fee for service and managed care medical |
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| 1 | | assistance programs for persons who are otherwise eligible for | 2 | | medical assistance under this Article and shall not be subject | 3 | | to any (1) utilization control, other than those established | 4 | | under the American Society of Addiction Medicine patient | 5 | | placement criteria,
(2) prior authorization mandate, or (3) | 6 | | lifetime restriction limit
mandate. | 7 | | On or after July 1, 2015, opioid antagonists prescribed | 8 | | for the treatment of an opioid overdose, including the | 9 | | medication product, administration devices, and any pharmacy | 10 | | fees or hospital fees related to the dispensing , distribution, | 11 | | and administration of the opioid antagonist, shall be covered | 12 | | under the medical assistance program for persons who are | 13 | | otherwise eligible for medical assistance under this Article. | 14 | | As used in this Section, "opioid antagonist" means a drug that | 15 | | binds to opioid receptors and blocks or inhibits the effect of | 16 | | opioids acting on those receptors, including, but not limited | 17 | | to, naloxone hydrochloride or any other similarly acting drug | 18 | | approved by the U.S. Food and Drug Administration. | 19 | | Upon federal approval, the Department shall provide | 20 | | coverage and reimbursement for all drugs that are approved for | 21 | | marketing by the federal Food and Drug Administration and that | 22 | | are recommended by the federal Public Health Service or the | 23 | | United States Centers for Disease Control and Prevention for | 24 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 25 | | services, including, but not limited to, HIV and sexually | 26 | | transmitted infection screening, treatment for sexually |
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| 1 | | transmitted infections, medical monitoring, assorted labs, and | 2 | | counseling to reduce the likelihood of HIV infection among | 3 | | individuals who are not infected with HIV but who are at high | 4 | | risk of HIV infection. | 5 | | A federally qualified health center, as defined in Section | 6 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 7 | | reimbursed by the Department in accordance with the federally | 8 | | qualified health center's encounter rate for services provided | 9 | | to medical assistance recipients that are performed by a | 10 | | dental hygienist, as defined under the Illinois Dental | 11 | | Practice Act, working under the general supervision of a | 12 | | dentist and employed by a federally qualified health center. | 13 | | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | 14 | | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | 15 | | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | 16 | | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | 17 | | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | 18 | | 1-1-20; revised 9-18-19.) | 19 | | (305 ILCS 5/5-41 new) | 20 | | Sec. 5-41. Screening, Brief Intervention, and Referral to | 21 | | Treatment. | 22 | | As used in this Section, "SBIRT" means a comprehensive, | 23 | | integrated, public health approach to the delivery of early | 24 | | intervention and treatment
services for persons who are at | 25 | | risk of developing substance use disorders or have substance |
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| 1 | | use disorders including, but not limited to, an addiction to | 2 | | alcohol, opioids,
tobacco, or cannabis.
SBIRT services include | 3 | | all of the following: | 4 | | (1) Screening to quickly assess the severity of | 5 | | substance use and to identify the appropriate level of | 6 | | treatment. | 7 | | (2) Brief intervention focused on increasing insight | 8 | | and awareness regarding substance use and motivation | 9 | | toward behavioral change. | 10 | | (3) Referral to treatment provided to those identified | 11 | | as needing more extensive treatment with access to | 12 | | specialty care. | 13 | | SBIRT services may include, but are not limited to, the | 14 | | following settings and programs: primary care centers, | 15 | | hospital emergency rooms, hospital in-patient units,
trauma | 16 | | centers, community behavioral health programs, and other | 17 | | community settings that provide opportunities for early | 18 | | intervention with at-risk substance users before more severe
| 19 | | consequences occur. | 20 | | The Department of Healthcare and Family Services shall | 21 | | develop and seek federal approval of a SBIRT benefit for which
| 22 | | qualified providers shall be reimbursed under the medical | 23 | | assistance program. | 24 | | In conjunction with the Department of Human Services' | 25 | | Division of Substance Use Prevention and Recovery, the | 26 | | Department of Healthcare and
Family Services may develop a |
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| 1 | | methodology and reimbursement rate for SBIRT services provided | 2 | | by qualified providers in approved
settings. | 3 | | For opioid specific SBIRT services provided in a hospital | 4 | | emergency department, the Department of Healthcare and
Family | 5 | | Services shall develop a bundled reimbursement
methodology and | 6 | | rate for a package of opioid treatment services, which include | 7 | | initiation of medication for the treatment of opioid use | 8 | | disorder in
the emergency department setting, including | 9 | | assessment, referral to ongoing care, and arranging access to | 10 | | supportive services when necessary. This
package of opioid | 11 | | related services shall be billed on a separate claim and shall | 12 | | be reimbursed outside of the Enhanced Ambulatory Patient
| 13 | | Grouping system. ".
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