Illinois General Assembly - Full Text of SB0346
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Full Text of SB0346  102nd General Assembly


Sen. Julie A. Morrison

Filed: 4/2/2021





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2    AMENDMENT NO. ______. Amend Senate Bill 346 by replacing
3everything after the enacting clause with the following:
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
16home, or elsewhere; (6) medical care, or any other type of



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1remedial care furnished by licensed practitioners; (7) home
2health care services; (8) private duty nursing service; (9)
3clinic services; (10) dental services, including prevention
4and treatment of periodontal disease and dental caries disease
5for pregnant women, provided by an individual licensed to
6practice dentistry or dental surgery; for purposes of this
7item (10), "dental services" means diagnostic, preventive, or
8corrective procedures provided by or under the supervision of
9a dentist in the practice of his or her profession; (11)
10physical therapy and related services; (12) prescribed drugs,
11dentures, and prosthetic devices; and eyeglasses prescribed by
12a physician skilled in the diseases of the eye, or by an
13optometrist, whichever the person may select; (13) other
14diagnostic, screening, preventive, and rehabilitative
15services, including to ensure that the individual's need for
16intervention or treatment of mental disorders or substance use
17disorders or co-occurring mental health and substance use
18disorders is determined using a uniform screening, assessment,
19and evaluation process inclusive of criteria, for children and
20adults; for purposes of this item (13), a uniform screening,
21assessment, and evaluation process refers to a process that
22includes an appropriate evaluation and, as warranted, a
23referral; "uniform" does not mean the use of a singular
24instrument, tool, or process that all must utilize; (14)
25transportation and such other expenses as may be necessary;
26(15) medical treatment of sexual assault survivors, as defined



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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the
3sexual assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; and (17) any other medical
7care, and any other type of remedial care recognized under the
8laws of this State. The term "any other type of remedial care"
9shall include nursing care and nursing home service for
10persons who rely on treatment by spiritual means alone through
11prayer for healing.
12    Notwithstanding any other provision of this Section, a
13comprehensive tobacco use cessation program that includes
14purchasing prescription drugs or prescription medical devices
15approved by the Food and Drug Administration shall be covered
16under the medical assistance program under this Article for
17persons who are otherwise eligible for assistance under this
19    Notwithstanding any other provision of this Code,
20reproductive health care that is otherwise legal in Illinois
21shall be covered under the medical assistance program for
22persons who are otherwise eligible for medical assistance
23under this Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a



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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured
14under this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare
24and Family Services may provide the following services to
25persons eligible for assistance under this Article who are
26participating in education, training or employment programs



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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in
6    the diseases of the eye, or by an optometrist, whichever
7    the person may select.
8    On and after July 1, 2018, the Department of Healthcare
9and Family Services shall provide dental services to any adult
10who is otherwise eligible for assistance under the medical
11assistance program. As used in this paragraph, "dental
12services" means diagnostic, preventative, restorative, or
13corrective procedures, including procedures and services for
14the prevention and treatment of periodontal disease and dental
15caries disease, provided by an individual who is licensed to
16practice dentistry or dental surgery or who is under the
17supervision of a dentist in the practice of his or her
19    On and after July 1, 2018, targeted dental services, as
20set forth in Exhibit D of the Consent Decree entered by the
21United States District Court for the Northern District of
22Illinois, Eastern Division, in the matter of Memisovski v.
23Maram, Case No. 92 C 1982, that are provided to adults under
24the medical assistance program shall be established at no less
25than the rates set forth in the "New Rate" column in Exhibit D
26of the Consent Decree for targeted dental services that are



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1provided to persons under the age of 18 under the medical
2assistance program.
3    Notwithstanding any other provision of this Code and
4subject to federal approval, the Department may adopt rules to
5allow a dentist who is volunteering his or her service at no
6cost to render dental services through an enrolled
7not-for-profit health clinic without the dentist personally
8enrolling as a participating provider in the medical
9assistance program. A not-for-profit health clinic shall
10include a public health clinic or Federally Qualified Health
11Center or other enrolled provider, as determined by the
12Department, through which dental services covered under this
13Section are performed. The Department shall establish a
14process for payment of claims for reimbursement for covered
15dental services rendered under this provision.
16    On and after January 1, 2022, the Department of Healthcare
17and Family Services shall administer and regulate a
18school-based dental program that allows for the out-of-office
19delivery of preventative dental services in a school setting
20to children under 19 years of age. The Department shall
21establish, by rule, guidelines for participation by providers
22and set requirements for follow-up referral care based on the
23requirements established in the Dental Office Reference Manual
24published by the Department that establishes the requirements
25for dentists participating in the All Kids Dental School
26Program. Every effort shall be made by the Department when



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1developing the program requirements to consider the different
2geographic differences of both urban and rural areas of the
3State for initial treatment and necessary follow-up care. No
4provider shall be charged a fee by any unit of local government
5to participate in the school-based dental program administered
6by the Department. Nothing in this paragraph shall be
7construed to limit or preempt a home rule unit's or school
8district's authority to establish, change, or administer a
9school-based dental program in addition to, or independent of,
10the school-based dental program administered by the
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in
14accordance with the classes of persons designated in Section
16    The Department of Healthcare and Family Services must
17provide coverage and reimbursement for amino acid-based
18elemental formulas, regardless of delivery method, for the
19diagnosis and treatment of (i) eosinophilic disorders and (ii)
20short bowel syndrome when the prescribing physician has issued
21a written order stating that the amino acid-based elemental
22formula is medically necessary.
23    The Illinois Department shall authorize the provision of,
24and shall authorize payment for, screening by low-dose
25mammography for the presence of occult breast cancer for women
2635 years of age or older who are eligible for medical



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1assistance under this Article, as follows:
2        (A) A baseline mammogram for women 35 to 39 years of
3    age.
4        (B) An annual mammogram for women 40 years of age or
5    older.
6        (C) A mammogram at the age and intervals considered
7    medically necessary by the woman's health care provider
8    for women under 40 years of age and having a family history
9    of breast cancer, prior personal history of breast cancer,
10    positive genetic testing, or other risk factors.
11        (D) A comprehensive ultrasound screening and MRI of an
12    entire breast or breasts if a mammogram demonstrates
13    heterogeneous or dense breast tissue or when medically
14    necessary as determined by a physician licensed to
15    practice medicine in all of its branches.
16        (E) A screening MRI when medically necessary, as
17    determined by a physician licensed to practice medicine in
18    all of its branches.
19        (F) A diagnostic mammogram when medically necessary,
20    as determined by a physician licensed to practice medicine
21    in all its branches, advanced practice registered nurse,
22    or physician assistant.
23    The Department shall not impose a deductible, coinsurance,
24copayment, or any other cost-sharing requirement on the
25coverage provided under this paragraph; except that this
26sentence does not apply to coverage of diagnostic mammograms



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1to the extent such coverage would disqualify a high-deductible
2health plan from eligibility for a health savings account
3pursuant to Section 223 of the Internal Revenue Code (26
4U.S.C. 223).
5    All screenings shall include a physical breast exam,
6instruction on self-examination and information regarding the
7frequency of self-examination and its value as a preventative
9     For purposes of this Section:
10    "Diagnostic mammogram" means a mammogram obtained using
11diagnostic mammography.
12    "Diagnostic mammography" means a method of screening that
13is designed to evaluate an abnormality in a breast, including
14an abnormality seen or suspected on a screening mammogram or a
15subjective or objective abnormality otherwise detected in the
17    "Low-dose mammography" means the x-ray examination of the
18breast using equipment dedicated specifically for mammography,
19including the x-ray tube, filter, compression device, and
20image receptor, with an average radiation exposure delivery of
21less than one rad per breast for 2 views of an average size
22breast. The term also includes digital mammography and
23includes breast tomosynthesis.
24    "Breast tomosynthesis" means a radiologic procedure that
25involves the acquisition of projection images over the
26stationary breast to produce cross-sectional digital



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1three-dimensional images of the breast.
2    If, at any time, the Secretary of the United States
3Department of Health and Human Services, or its successor
4agency, promulgates rules or regulations to be published in
5the Federal Register or publishes a comment in the Federal
6Register or issues an opinion, guidance, or other action that
7would require the State, pursuant to any provision of the
8Patient Protection and Affordable Care Act (Public Law
9111-148), including, but not limited to, 42 U.S.C.
1018031(d)(3)(B) or any successor provision, to defray the cost
11of any coverage for breast tomosynthesis outlined in this
12paragraph, then the requirement that an insurer cover breast
13tomosynthesis is inoperative other than any such coverage
14authorized under Section 1902 of the Social Security Act, 42
15U.S.C. 1396a, and the State shall not assume any obligation
16for the cost of coverage for breast tomosynthesis set forth in
17this paragraph.
18    On and after January 1, 2016, the Department shall ensure
19that all networks of care for adult clients of the Department
20include access to at least one breast imaging Center of
21Imaging Excellence as certified by the American College of
23    On and after January 1, 2012, providers participating in a
24quality improvement program approved by the Department shall
25be reimbursed for screening and diagnostic mammography at the
26same rate as the Medicare program's rates, including the



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



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1who have not received a mammogram within the previous 18
2months, of the importance and benefit of screening
3mammography. The Department shall work with experts in breast
4cancer outreach and patient navigation to optimize these
5reminders and shall establish a methodology for evaluating
6their effectiveness and modifying the methodology based on the
8    The Department shall establish a performance goal for
9primary care providers with respect to their female patients
10over age 40 receiving an annual mammogram. This performance
11goal shall be used to provide additional reimbursement in the
12form of a quality performance bonus to primary care providers
13who meet that goal.
14    The Department shall devise a means of case-managing or
15patient navigation for beneficiaries diagnosed with breast
16cancer. This program shall initially operate as a pilot
17program in areas of the State with the highest incidence of
18mortality related to breast cancer. At least one pilot program
19site shall be in the metropolitan Chicago area and at least one
20site shall be outside the metropolitan Chicago area. On or
21after July 1, 2016, the pilot program shall be expanded to
22include one site in western Illinois, one site in southern
23Illinois, one site in central Illinois, and 4 sites within
24metropolitan Chicago. An evaluation of the pilot program shall
25be carried out measuring health outcomes and cost of care for
26those served by the pilot program compared to similarly



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1situated patients who are not served by the pilot program.
2    The Department shall require all networks of care to
3develop a means either internally or by contract with experts
4in navigation and community outreach to navigate cancer
5patients to comprehensive care in a timely fashion. The
6Department shall require all networks of care to include
7access for patients diagnosed with cancer to at least one
8academic commission on cancer-accredited cancer program as an
9in-network covered benefit.
10    Any medical or health care provider shall immediately
11recommend, to any pregnant woman who is being provided
12prenatal services and is suspected of having a substance use
13disorder as defined in the Substance Use Disorder Act,
14referral to a local substance use disorder treatment program
15licensed by the Department of Human Services or to a licensed
16hospital which provides substance abuse treatment services.
17The Department of Healthcare and Family Services shall assure
18coverage for the cost of treatment of the drug abuse or
19addiction for pregnant recipients in accordance with the
20Illinois Medicaid Program in conjunction with the Department
21of Human Services.
22    All medical providers providing medical assistance to
23pregnant women under this Code shall receive information from
24the Department on the availability of services under any
25program providing case management services for addicted women,
26including information on appropriate referrals for other



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



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



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



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



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1basis, be deemed adequate by the Illinois Department to assure
2that such drugs, dentures, prosthetic devices and eyeglasses
3for which payment is being made are actually being received by
4eligible recipients. Within 90 days after September 16, 1984
5(the effective date of Public Act 83-1439), the Illinois
6Department shall establish a current list of acquisition costs
7for all prosthetic devices and any other items recognized as
8medical equipment and supplies reimbursable under this Article
9and shall update such list on a quarterly basis, except that
10the acquisition costs of all prescription drugs shall be
11updated no less frequently than every 30 days as required by
12Section 5-5.12.
13    Notwithstanding any other law to the contrary, the
14Illinois Department shall, within 365 days after July 22, 2013
15(the effective date of Public Act 98-104), establish
16procedures to permit skilled care facilities licensed under
17the Nursing Home Care Act to submit monthly billing claims for
18reimbursement purposes. Following development of these
19procedures, the Department shall, by July 1, 2016, test the
20viability of the new system and implement any necessary
21operational or structural changes to its information
22technology platforms in order to allow for the direct
23acceptance and payment of nursing home claims.
24    Notwithstanding any other law to the contrary, the
25Illinois Department shall, within 365 days after August 15,
262014 (the effective date of Public Act 98-963), establish



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



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1period and shall be conditional for one year. During the
2period of conditional enrollment, the Department may terminate
3the vendor's eligibility to participate in, or may disenroll
4the vendor from, the medical assistance program without cause.
5Unless otherwise specified, such termination of eligibility or
6disenrollment is not subject to the Department's hearing
7process. However, a disenrolled vendor may reapply without
9    The Department has the discretion to limit the conditional
10enrollment period for vendors based upon category of risk of
11the vendor.
12    Prior to enrollment and during the conditional enrollment
13period in the medical assistance program, all vendors shall be
14subject to enhanced oversight, screening, and review based on
15the risk of fraud, waste, and abuse that is posed by the
16category of risk of the vendor. The Illinois Department shall
17establish the procedures for oversight, screening, and review,
18which may include, but need not be limited to: criminal and
19financial background checks; fingerprinting; license,
20certification, and authorization verifications; unscheduled or
21unannounced site visits; database checks; prepayment audit
22reviews; audits; payment caps; payment suspensions; and other
23screening as required by federal or State law.
24    The Department shall define or specify the following: (i)
25by provider notice, the "category of risk of the vendor" for
26each type of vendor, which shall take into account the level of



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



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1        (4) In the case of a provider operated by a unit of
2    local government with a population exceeding 3,000,000
3    when local government funds finance federal participation
4    for claims payments.
5    For claims for services rendered during a period for which
6a recipient received retroactive eligibility, claims must be
7filed within 180 days after the Department determines the
8applicant is eligible. For claims for which the Illinois
9Department is not the primary payer, claims must be submitted
10to the Illinois Department within 180 days after the final
11adjudication by the primary payer.
12    In the case of long term care facilities, within 45
13calendar days of receipt by the facility of required
14prescreening information, new admissions with associated
15admission documents shall be submitted through the Medical
16Electronic Data Interchange (MEDI) or the Recipient
17Eligibility Verification (REV) System or shall be submitted
18directly to the Department of Human Services using required
19admission forms. Effective September 1, 2014, admission
20documents, including all prescreening information, must be
21submitted through MEDI or REV. Confirmation numbers assigned
22to an accepted transaction shall be retained by a facility to
23verify timely submittal. Once an admission transaction has
24been completed, all resubmitted claims following prior
25rejection are subject to receipt no later than 180 days after
26the admission transaction has been completed.



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



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



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



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1    In order to promote environmental responsibility, meet the
2needs of recipients and enrollees, and achieve significant
3cost savings, the Department, or a managed care organization
4under contract with the Department, may provide recipients or
5managed care enrollees who have a prescription or Certificate
6of Medical Necessity access to refurbished durable medical
7equipment under this Section (excluding prosthetic and
8orthotic devices as defined in the Orthotics, Prosthetics, and
9Pedorthics Practice Act and complex rehabilitation technology
10products and associated services) through the State's
11assistive technology program's reutilization program, using
12staff with the Assistive Technology Professional (ATP)
13Certification if the refurbished durable medical equipment:
14(i) is available; (ii) is less expensive, including shipping
15costs, than new durable medical equipment of the same type;
16(iii) is able to withstand at least 3 years of use; (iv) is
17cleaned, disinfected, sterilized, and safe in accordance with
18federal Food and Drug Administration regulations and guidance
19governing the reprocessing of medical devices in health care
20settings; and (v) equally meets the needs of the recipient or
21enrollee. The reutilization program shall confirm that the
22recipient or enrollee is not already in receipt of same or
23similar equipment from another service provider, and that the
24refurbished durable medical equipment equally meets the needs
25of the recipient or enrollee. Nothing in this paragraph shall
26be construed to limit recipient or enrollee choice to obtain



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1new durable medical equipment or place any additional prior
2authorization conditions on enrollees of managed care
4    The Department shall execute, relative to the nursing home
5prescreening project, written inter-agency agreements with the
6Department of Human Services and the Department on Aging, to
7effect the following: (i) intake procedures and common
8eligibility criteria for those persons who are receiving
9non-institutional services; and (ii) the establishment and
10development of non-institutional services in areas of the
11State where they are not currently available or are
12undeveloped; and (iii) notwithstanding any other provision of
13law, subject to federal approval, on and after July 1, 2012, an
14increase in the determination of need (DON) scores from 29 to
1537 for applicants for institutional and home and
16community-based long term care; if and only if federal
17approval is not granted, the Department may, in conjunction
18with other affected agencies, implement utilization controls
19or changes in benefit packages to effectuate a similar savings
20amount for this population; and (iv) no later than July 1,
212013, minimum level of care eligibility criteria for
22institutional and home and community-based long term care; and
23(v) no later than October 1, 2013, establish procedures to
24permit long term care providers access to eligibility scores
25for individuals with an admission date who are seeking or
26receiving services from the long term care provider. In order



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1to select the minimum level of care eligibility criteria, the
2Governor shall establish a workgroup that includes affected
3agency representatives and stakeholders representing the
4institutional and home and community-based long term care
5interests. This Section shall not restrict the Department from
6implementing lower level of care eligibility criteria for
7community-based services in circumstances where federal
8approval has been granted.
9    The Illinois Department shall develop and operate, in
10cooperation with other State Departments and agencies and in
11compliance with applicable federal laws and regulations,
12appropriate and effective systems of health care evaluation
13and programs for monitoring of utilization of health care
14services and facilities, as it affects persons eligible for
15medical assistance under this Code.
16    The Illinois Department shall report annually to the
17General Assembly, no later than the second Friday in April of
181979 and each year thereafter, in regard to:
19        (a) actual statistics and trends in utilization of
20    medical services by public aid recipients;
21        (b) actual statistics and trends in the provision of
22    the various medical services by medical vendors;
23        (c) current rate structures and proposed changes in
24    those rate structures for the various medical vendors; and
25        (d) efforts at utilization review and control by the
26    Illinois Department.



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1    The period covered by each report shall be the 3 years
2ending on the June 30 prior to the report. The report shall
3include suggested legislation for consideration by the General
4Assembly. The requirement for reporting to the General
5Assembly shall be satisfied by filing copies of the report as
6required by Section 3.1 of the General Assembly Organization
7Act, and filing such additional copies with the State
8Government Report Distribution Center for the General Assembly
9as is required under paragraph (t) of Section 7 of the State
10Library Act.
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
20of reimbursement for services or other payments in accordance
21with Section 5-5e.
22    Because kidney transplantation can be an appropriate,
23cost-effective alternative to renal dialysis when medically
24necessary and notwithstanding the provisions of Section 1-11
25of this Code, beginning October 1, 2014, the Department shall
26cover kidney transplantation for noncitizens with end-stage



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1renal disease who are not eligible for comprehensive medical
2benefits, who meet the residency requirements of Section 5-3
3of this Code, and who would otherwise meet the financial
4requirements of the appropriate class of eligible persons
5under Section 5-2 of this Code. To qualify for coverage of
6kidney transplantation, such person must be receiving
7emergency renal dialysis services covered by the Department.
8Providers under this Section shall be prior approved and
9certified by the Department to perform kidney transplantation
10and the services under this Section shall be limited to
11services associated with kidney 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
24for the treatment of an opioid overdose, including the
25medication product, administration devices, and any pharmacy
26fees related to the dispensing and administration of the



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1opioid antagonist, shall be covered under the medical
2assistance program for persons who are otherwise eligible for
3medical assistance under this Article. As used in this
4Section, "opioid antagonist" means a drug that binds to opioid
5receptors and blocks or inhibits the effect of opioids acting
6on those receptors, including, but not limited to, naloxone
7hydrochloride or any other similarly acting drug approved by
8the U.S. Food and Drug Administration.
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    A federally qualified health center, as defined in Section
221905(l)(2)(B) of the federal Social Security Act, shall be
23reimbursed by the Department in accordance with the federally
24qualified health center's encounter rate for services provided
25to medical assistance recipients that are performed by a
26dental hygienist, as defined under the Illinois Dental



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1Practice Act, working under the general supervision of a
2dentist and employed by a federally qualified health center.
3(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
4100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
56-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
6eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
7100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
81-1-20; revised 9-18-19.)
9    Section 99. Effective date. This Act takes effect January
101, 2022.".