Illinois General Assembly - Full Text of SB2384
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Full Text of SB2384  102nd General Assembly


Rep. Robyn Gabel

Filed: 5/28/2021





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2    AMENDMENT NO. ______. Amend Senate Bill 2384 by replacing
3everything after the enacting clause with the following:
4    "Section 1. Amends the Illinois Public Aid Code is amended
5by changing 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    The Illinois Department, by rule, may distinguish and
17classify the medical services to be provided only in
18accordance with the classes of persons designated in Section
20    The Department of Healthcare and Family Services must
21provide coverage and reimbursement for amino acid-based
22elemental formulas, regardless of delivery method, for the
23diagnosis and treatment of (i) eosinophilic disorders and (ii)
24short bowel syndrome when the prescribing physician has issued
25a written order stating that the amino acid-based elemental
26formula is medically necessary.



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1    The Illinois Department shall authorize the provision of,
2and shall authorize payment for, screening by low-dose
3mammography for the presence of occult breast cancer for women
435 years of age or older who are eligible for medical
5assistance under this Article, as follows:
6        (A) A baseline mammogram for women 35 to 39 years of
7    age.
8        (B) An annual mammogram for women 40 years of age or
9    older.
10        (C) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider
12    for women under 40 years of age and having a family history
13    of breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (D) A comprehensive ultrasound screening and MRI of an
16    entire breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue or when medically
18    necessary as determined by a physician licensed to
19    practice medicine in all of its branches.
20        (E) A screening MRI when medically necessary, as
21    determined by a physician licensed to practice medicine in
22    all of its branches.
23        (F) A diagnostic mammogram when medically necessary,
24    as determined by a physician licensed to practice medicine
25    in all its branches, advanced practice registered nurse,
26    or physician assistant.



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1    The Department shall not impose a deductible, coinsurance,
2copayment, or any other cost-sharing requirement on the
3coverage provided under this paragraph; except that this
4sentence does not apply to coverage of diagnostic mammograms
5to the extent such coverage would disqualify a high-deductible
6health plan from eligibility for a health savings account
7pursuant to Section 223 of the Internal Revenue Code (26
8U.S.C. 223).
9    All screenings shall include a physical breast exam,
10instruction on self-examination and information regarding the
11frequency of self-examination and its value as a preventative
13     For purposes of this Section:
14    "Diagnostic mammogram" means a mammogram obtained using
15diagnostic mammography.
16    "Diagnostic mammography" means a method of screening that
17is designed to evaluate an abnormality in a breast, including
18an abnormality seen or suspected on a screening mammogram or a
19subjective or objective abnormality otherwise detected in the
21    "Low-dose mammography" means the x-ray examination of the
22breast using equipment dedicated specifically for mammography,
23including the x-ray tube, filter, compression device, and
24image receptor, with an average radiation exposure delivery of
25less than one rad per breast for 2 views of an average size
26breast. The term also includes digital mammography and



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1includes breast tomosynthesis.
2    "Breast tomosynthesis" means a radiologic procedure that
3involves the acquisition of projection images over the
4stationary breast to produce cross-sectional digital
5three-dimensional images of the breast.
6    If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage for breast tomosynthesis outlined in this
16paragraph, then the requirement that an insurer cover breast
17tomosynthesis is inoperative other than any such coverage
18authorized under Section 1902 of the Social Security Act, 42
19U.S.C. 1396a, and the State shall not assume any obligation
20for the cost of coverage for breast tomosynthesis set forth in
21this paragraph.
22    On and after January 1, 2016, the Department shall ensure
23that all networks of care for adult clients of the Department
24include access to at least one breast imaging Center of
25Imaging Excellence as certified by the American College of



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



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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening
7mammography. The Department shall work with experts in breast
8cancer outreach and patient navigation to optimize these
9reminders and shall establish a methodology for evaluating
10their effectiveness and modifying the methodology based on the
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot
21program in areas of the State with the highest incidence of
22mortality related to breast cancer. At least one pilot program
23site shall be in the metropolitan Chicago area and at least one
24site shall be outside the metropolitan Chicago area. On or
25after July 1, 2016, the pilot program shall be expanded to
26include one site in western Illinois, one site in southern



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



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



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



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



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1implementation of Partnerships under this Section.
2    The Illinois Department shall require health care
3providers to maintain records that document the medical care
4and services provided to recipients of Medical Assistance
5under this Article. Such records must be retained for a period
6of not less than 6 years from the date of service or as
7provided by applicable State law, whichever period is longer,
8except that if an audit is initiated within the required
9retention period then the records must be retained until the
10audit is completed and every exception is resolved. The
11Illinois Department shall require health care providers to
12make available, when authorized by the patient, in writing,
13the medical records in a timely fashion to other health care
14providers who are treating or serving persons eligible for
15Medical Assistance under this Article. All dispensers of
16medical services shall be required to maintain and retain
17business and professional records sufficient to fully and
18accurately document the nature, scope, details and receipt of
19the health care provided to persons eligible for medical
20assistance under this Code, in accordance with regulations
21promulgated by the Illinois Department. The rules and
22regulations shall require that proof of the receipt of
23prescription drugs, dentures, prosthetic devices and
24eyeglasses by eligible persons under this Section accompany
25each claim for reimbursement submitted by the dispenser of
26such medical services. No such claims for reimbursement shall



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1be approved for payment by the Illinois Department without
2such proof of receipt, unless the Illinois Department shall
3have put into effect and shall be operating a system of
4post-payment audit and review which shall, on a sampling
5basis, be deemed adequate by the Illinois Department to assure
6that such drugs, dentures, prosthetic devices and eyeglasses
7for which payment is being made are actually being received by
8eligible recipients. Within 90 days after September 16, 1984
9(the effective date of Public Act 83-1439), the Illinois
10Department shall establish a current list of acquisition costs
11for all prosthetic devices and any other items recognized as
12medical equipment and supplies reimbursable under this Article
13and shall update such list on a quarterly basis, except that
14the acquisition costs of all prescription drugs shall be
15updated no less frequently than every 30 days as required by
16Section 5-5.12.
17    Notwithstanding any other law to the contrary, the
18Illinois Department shall, within 365 days after July 22, 2013
19(the effective date of Public Act 98-104), establish
20procedures to permit skilled care facilities licensed under
21the Nursing Home Care Act to submit monthly billing claims for
22reimbursement purposes. Following development of these
23procedures, the Department shall, by July 1, 2016, test the
24viability of the new system and implement any necessary
25operational or structural changes to its information
26technology platforms in order to allow for the direct



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1acceptance and payment of nursing home claims.
2    Notwithstanding any other law to the contrary, the
3Illinois Department shall, within 365 days after August 15,
42014 (the effective date of Public Act 98-963), establish
5procedures to permit ID/DD facilities licensed under the ID/DD
6Community Care Act and MC/DD facilities licensed under the
7MC/DD Act to submit monthly billing claims for reimbursement
8purposes. Following development of these procedures, the
9Department shall have an additional 365 days to test the
10viability of the new system and to ensure that any necessary
11operational or structural changes to its information
12technology platforms are implemented.
13    The Illinois Department shall require all dispensers of
14medical services, other than an individual practitioner or
15group of practitioners, desiring to participate in the Medical
16Assistance program established under this Article to disclose
17all financial, beneficial, ownership, equity, surety or other
18interests in any and all firms, corporations, partnerships,
19associations, business enterprises, joint ventures, agencies,
20institutions or other legal entities providing any form of
21health care services in this State under this Article.
22    The Illinois Department may require that all dispensers of
23medical services desiring to participate in the medical
24assistance program established under this Article disclose,
25under such terms and conditions as the Illinois Department may
26by rule establish, all inquiries from clients and attorneys



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1regarding medical bills paid by the Illinois Department, which
2inquiries could indicate potential existence of claims or
3liens for the Illinois Department.
4    Enrollment of a vendor shall be subject to a provisional
5period and shall be conditional for one year. During the
6period of conditional enrollment, the Department may terminate
7the vendor's eligibility to participate in, or may disenroll
8the vendor from, the medical assistance program without cause.
9Unless otherwise specified, such termination of eligibility or
10disenrollment is not subject to the Department's hearing
11process. However, a disenrolled vendor may reapply without
13    The Department has the discretion to limit the conditional
14enrollment period for vendors based upon category of risk of
15the vendor.
16    Prior to enrollment and during the conditional enrollment
17period in the medical assistance program, all vendors shall be
18subject to enhanced oversight, screening, and review based on
19the risk of fraud, waste, and abuse that is posed by the
20category of risk of the vendor. The Illinois Department shall
21establish the procedures for oversight, screening, and review,
22which may include, but need not be limited to: criminal and
23financial background checks; fingerprinting; license,
24certification, and authorization verifications; unscheduled or
25unannounced site visits; database checks; prepayment audit
26reviews; audits; payment caps; payment suspensions; and other



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1screening as required by federal or State law.
2    The Department shall define or specify the following: (i)
3by provider notice, the "category of risk of the vendor" for
4each type of vendor, which shall take into account the level of
5screening applicable to a particular category of vendor under
6federal law and regulations; (ii) by rule or provider notice,
7the maximum length of the conditional enrollment period for
8each category of risk of the vendor; and (iii) by rule, the
9hearing rights, if any, afforded to a vendor in each category
10of risk of the vendor that is terminated or disenrolled during
11the conditional enrollment period.
12    To be eligible for payment consideration, a vendor's
13payment claim or bill, either as an initial claim or as a
14resubmitted claim following prior rejection, must be received
15by the Illinois Department, or its fiscal intermediary, no
16later than 180 days after the latest date on the claim on which
17medical goods or services were provided, with the following
19        (1) In the case of a provider whose enrollment is in
20    process by the Illinois Department, the 180-day period
21    shall not begin until the date on the written notice from
22    the Illinois Department that the provider enrollment is
23    complete.
24        (2) In the case of errors attributable to the Illinois
25    Department or any of its claims processing intermediaries
26    which result in an inability to receive, process, or



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



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



10200SB2384ham002- 23 -LRB102 16996 KTG 27033 a

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



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1take any action or acquire any products or services.
2    The Illinois Department shall establish policies,
3procedures, standards and criteria by rule for the
4acquisition, repair and replacement of orthotic and prosthetic
5devices and durable medical equipment. Such rules shall
6provide, but not be limited to, the following services: (1)
7immediate repair or replacement of such devices by recipients;
8and (2) rental, lease, purchase or lease-purchase of durable
9medical equipment in a cost-effective manner, taking into
10consideration the recipient's medical prognosis, the extent of
11the recipient's needs, and the requirements and costs for
12maintaining such equipment. Subject to prior approval, such
13rules shall enable a recipient to temporarily acquire and use
14alternative or substitute devices or equipment pending repairs
15or replacements of any device or equipment previously
16authorized for such recipient by the Department.
17Notwithstanding any provision of Section 5-5f to the contrary,
18the Department may, by rule, exempt certain replacement
19wheelchair parts from prior approval and, for wheelchairs,
20wheelchair parts, wheelchair accessories, and related seating
21and positioning items, determine the wholesale price by
22methods other than actual acquisition costs.
23    The Department shall require, by rule, all providers of
24durable medical equipment to be accredited by an accreditation
25organization approved by the federal Centers for Medicare and
26Medicaid Services and recognized by the Department in order to



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1bill the Department for providing durable medical equipment to
2recipients. No later than 15 months after the effective date
3of the rule adopted pursuant to this paragraph, all providers
4must meet the accreditation requirement.
5    In order to promote environmental responsibility, meet the
6needs of recipients and enrollees, and achieve significant
7cost savings, the Department, or a managed care organization
8under contract with the Department, may provide recipients or
9managed care enrollees who have a prescription or Certificate
10of Medical Necessity access to refurbished durable medical
11equipment under this Section (excluding prosthetic and
12orthotic devices as defined in the Orthotics, Prosthetics, and
13Pedorthics Practice Act and complex rehabilitation technology
14products and associated services) through the State's
15assistive technology program's reutilization program, using
16staff with the Assistive Technology Professional (ATP)
17Certification if the refurbished durable medical equipment:
18(i) is available; (ii) is less expensive, including shipping
19costs, than new durable medical equipment of the same type;
20(iii) is able to withstand at least 3 years of use; (iv) is
21cleaned, disinfected, sterilized, and safe in accordance with
22federal Food and Drug Administration regulations and guidance
23governing the reprocessing of medical devices in health care
24settings; and (v) equally meets the needs of the recipient or
25enrollee. The reutilization program shall confirm that the
26recipient or enrollee is not already in receipt of same or



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1similar equipment from another service provider, and that the
2refurbished durable medical equipment equally meets the needs
3of the recipient or enrollee. Nothing in this paragraph shall
4be construed to limit recipient or enrollee choice to obtain
5new durable medical equipment or place any additional prior
6authorization conditions on enrollees of managed care
8    The Department shall execute, relative to the nursing home
9prescreening project, written inter-agency agreements with the
10Department of Human Services and the Department on Aging, to
11effect the following: (i) intake procedures and common
12eligibility criteria for those persons who are receiving
13non-institutional services; and (ii) the establishment and
14development of non-institutional services in areas of the
15State where they are not currently available or are
16undeveloped; and (iii) notwithstanding any other provision of
17law, subject to federal approval, on and after July 1, 2012, an
18increase in the determination of need (DON) scores from 29 to
1937 for applicants for institutional and home and
20community-based long term care; if and only if federal
21approval is not granted, the Department may, in conjunction
22with other affected agencies, implement utilization controls
23or changes in benefit packages to effectuate a similar savings
24amount for this population; and (iv) no later than July 1,
252013, minimum level of care eligibility criteria for
26institutional and home and community-based long term care; and



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1(v) no later than October 1, 2013, establish procedures to
2permit long term care providers access to eligibility scores
3for individuals with an admission date who are seeking or
4receiving services from the long term care provider. In order
5to select the minimum level of care eligibility criteria, the
6Governor shall establish a workgroup that includes affected
7agency representatives and stakeholders representing the
8institutional and home and community-based long term care
9interests. This Section shall not restrict the Department from
10implementing lower level of care eligibility criteria for
11community-based services in circumstances where federal
12approval has been granted.
13    The Illinois Department shall develop and operate, in
14cooperation with other State Departments and agencies and in
15compliance with applicable federal laws and regulations,
16appropriate and effective systems of health care evaluation
17and programs for monitoring of utilization of health care
18services and facilities, as it affects persons eligible for
19medical assistance under this Code.
20    The Illinois Department shall report annually to the
21General Assembly, no later than the second Friday in April of
221979 and each year thereafter, in regard to:
23        (a) actual statistics and trends in utilization of
24    medical services by public aid recipients;
25        (b) actual statistics and trends in the provision of
26    the various medical services by medical vendors;



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1        (c) current rate structures and proposed changes in
2    those rate structures for the various medical vendors; and
3        (d) efforts at utilization review and control by the
4    Illinois Department.
5    The period covered by each report shall be the 3 years
6ending on the June 30 prior to the report. The report shall
7include suggested legislation for consideration by the General
8Assembly. The requirement for reporting to the General
9Assembly shall be satisfied by filing copies of the report as
10required by Section 3.1 of the General Assembly Organization
11Act, and filing such additional copies with the State
12Government Report Distribution Center for the General Assembly
13as is required under paragraph (t) of Section 7 of the State
14Library Act.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21    On and after July 1, 2012, the Department shall reduce any
22rate of reimbursement for services or other payments or alter
23any methodologies authorized by this Code to reduce any rate
24of reimbursement for services or other payments in accordance
25with Section 5-5e.
26    Because kidney transplantation can be an appropriate,



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1cost-effective alternative to renal dialysis when medically
2necessary and notwithstanding the provisions of Section 1-11
3of this Code, beginning October 1, 2014, the Department shall
4cover kidney transplantation for noncitizens with end-stage
5renal disease who are not eligible for comprehensive medical
6benefits, who meet the residency requirements of Section 5-3
7of this Code, and who would otherwise meet the financial
8requirements of the appropriate class of eligible persons
9under Section 5-2 of this Code. To qualify for coverage of
10kidney transplantation, such person must be receiving
11emergency renal dialysis services covered by the Department.
12Providers under this Section shall be prior approved and
13certified by the Department to perform kidney transplantation
14and the services under this Section shall be limited to
15services associated with kidney transplantation.
16    Notwithstanding any other provision of this Code to the
17contrary, on or after July 1, 2015, all FDA approved forms of
18medication assisted treatment prescribed for the treatment of
19alcohol dependence or treatment of opioid dependence shall be
20covered under both fee for service and managed care medical
21assistance programs for persons who are otherwise eligible for
22medical assistance under this Article and shall not be subject
23to any (1) utilization control, other than those established
24under the American Society of Addiction Medicine patient
25placement criteria, (2) prior authorization mandate, or (3)
26lifetime restriction limit mandate.



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1    On or after July 1, 2015, opioid antagonists prescribed
2for the treatment of an opioid overdose, including the
3medication product, administration devices, and any pharmacy
4fees related to the dispensing and administration of the
5opioid antagonist, shall be covered under the medical
6assistance program for persons who are otherwise eligible for
7medical assistance under this Article. As used in this
8Section, "opioid antagonist" means a drug that binds to opioid
9receptors and blocks or inhibits the effect of opioids acting
10on those receptors, including, but not limited to, naloxone
11hydrochloride or any other similarly acting drug approved by
12the U.S. Food and Drug Administration.
13    Upon federal approval, the Department shall provide
14coverage and reimbursement for all drugs that are approved for
15marketing by the federal Food and Drug Administration and that
16are recommended by the federal Public Health Service or the
17United States Centers for Disease Control and Prevention for
18pre-exposure prophylaxis and related pre-exposure prophylaxis
19services, including, but not limited to, HIV and sexually
20transmitted infection screening, treatment for sexually
21transmitted infections, medical monitoring, assorted labs, and
22counseling to reduce the likelihood of HIV infection among
23individuals who are not infected with HIV but who are at high
24risk of HIV infection.
25    A federally qualified health center, as defined in Section
261905(l)(2)(B) of the federal Social Security Act, shall be



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1reimbursed by the Department in accordance with the federally
2qualified health center's encounter rate for services provided
3to medical assistance recipients that are performed by a
4dental hygienist, as defined under the Illinois Dental
5Practice Act, working under the general supervision of a
6dentist and employed by a federally qualified health center.
7    Notwithstanding any other provision of this Code,
8community-based pediatric palliative care from a trained
9interdisciplinary team shall be covered under the medical
10assistance program as provided in Section 15 of the Pediatric
11Palliative Care Act.
12(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
13100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
146-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
15eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
16100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
171-1-20; revised 9-18-19.)
18    Section 5. The Pediatric Palliative Care Act is amended by
19changing Sections 5, 10, 15, 20, 25, 30, 35, 40, and 45 and by
20adding Section 37 as follows:
21    (305 ILCS 60/5)
22    Sec. 5. Legislative findings. The General Assembly finds
23as follows:
24        (1) Each year, approximately 1,500 1,185 Illinois



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1    children are diagnosed with a serious illness potentially
2    life-limiting illness.
3        (2) There are many barriers to the provision of
4    pediatric palliative services, the most significant of
5    which include the following: (i) challenges in predicting
6    life expectancy; (ii) the reluctance of families and
7    professionals to acknowledge a child's incurable
8    condition; and (iii) the lack of an appropriate,
9    pediatric-focused reimbursement structure leading to
10    insufficient community-based resources.
11        (3) Community-based pediatric palliative services have
12    been shown to keep children out of the hospital by
13    managing many symptoms in the home setting, thereby
14    improving childhood quality of life while maintaining
15    budget neutrality. It is tremendously difficult for
16    physicians to prognosticate pediatric life expectancy due
17    to the resiliency of children. In addition, parents are
18    rarely prepared to cease curative efforts in order to
19    receive hospice or palliative care. Community-based
20    pediatric palliative services, however, keep children out
21    of the hospital by managing many symptoms in the home
22    setting, thereby improving childhood quality of life while
23    maintaining budget neutrality.
24        (4) Pediatric palliative programming can, and should,
25    be administered in a cost neutral fashion. Community-based
26    pediatric palliative care allows for children and families



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1    to receive pain and symptom management and psychosocial
2    support in the comfort of the home setting, thereby
3    avoiding excess spending for emergency room visits and
4    certain hospitals. The National Hospice and Palliative
5    Care Organization's pediatric task force reported during
6    2001 that the average cost per child per year, cared for
7    primarily at home, receiving comprehensive palliative and
8    life prolonging services concurrently, is $16,177,
9    significantly less than the $19,000 to $48,000 per child
10    per year when palliative programs are not utilized.
11(Source: P.A. 96-1078, eff. 7-16-10.)
12    (305 ILCS 60/10)
13    Sec. 10. Definitions Definition. In this Act: ,
14    "Department" means the Department of Healthcare and Family
16    "Palliative care" means care focused on expert assessment
17and management of pain and other symptoms, assessment and
18support of caregiver needs, and coordination of care.
19Palliative care attends to the physical, functional,
20psychological, practical, and spiritual consequences of a
21serious illness. It is a person-centered and family-centered
22approach to care, providing people living with serious illness
23relief from the symptoms and stress of an illness. Through
24early integration into the care plan for the seriously ill,
25palliative care improves quality of life for the patient and



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1the family. Palliative care can be offered in all care
2settings and at any stage in a serious illness through
3collaboration of many types of care providers.
4    "Serious illness" means a health condition identified in
5Section 25 that carries a high risk of mortality and
6negatively impacts a person's daily function or quality of
8(Source: P.A. 96-1078, eff. 7-16-10.)
9    (305 ILCS 60/15)
10    Sec. 15. Pediatric palliative care pilot program. The
11Department shall develop a pediatric palliative care pilot
12program, and the medical assistance program established under
13Article V of the Illinois Public Aid Code shall cover under
14which a qualifying child as defined in Section 25 may receive
15community-based pediatric palliative care from a trained
16interdisciplinary team, as an added benefit under which a
17qualifying child, as defined in Section 25, may also choose to
18continue while continuing to pursue aggressive curative or
19disease-directed treatments for a serious potentially
20life-limiting illness under the benefits available under
21Article V of the Illinois Public Aid Code.
22(Source: P.A. 96-1078, eff. 7-16-10.)
23    (305 ILCS 60/20)
24    Sec. 20. Federal waiver or State Plan amendment. If



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1applicable, the The Department shall submit the necessary
2application to the federal Centers for Medicare and Medicaid
3Services for a waiver or State Plan amendment to implement the
4pilot program described in this Act. If the application is in
5the form of a State Plan amendment, the State Plan amendment
6shall be filed prior to December 31, 2010. If the Department
7does not submit a State Plan amendment prior to December 31,
82010, the pilot program shall be created utilizing a waiver
9authority. The waiver request shall be included in any
10appropriate waiver application renewal submitted prior to
11December 31, 2011, or shall be submitted as an independent
121915(c) Home and Community Based Medicaid Waiver within that
13same time period. After federal approval is secured, the
14Department shall implement the waiver or State Plan amendment
15within 12 months of the date of approval. The Department shall
16not draft any rules in contravention of this timetable for
17program development and implementation. By federal
18requirement, the application for a 1915 (c) Medicaid waiver
19program must demonstrate cost neutrality per the formula laid
20out by the Centers for Medicare and Medicaid Services. The
21Department shall not draft any rules in contravention of this
22timetable for pilot program development and implementation.
23This pilot program shall be implemented only to the extent
24that federal financial participation is available.
25(Source: P.A. 96-1078, eff. 7-16-10.)



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1    (305 ILCS 60/25)
2    Sec. 25. Qualifying child.
3    (a) For the purposes of this Act, a qualifying child is a
4person under 21 18 years of age who is enrolled in the medical
5assistance program under Article V of the Illinois Public Aid
6Code and is diagnosed by the child's primary physician or
7specialist as suffering from a serious illness and suffers
8from a potentially life-limiting medical condition, as defined
9in subsection (b). A child who is enrolled in the pilot program
10prior to the age 18 may continue to receive services under the
11pilot program until the day before his or her twenty-first
13    (b) The Department, in consultation with interested
14stakeholders, shall determine the serious illnesses
15potentially life-limiting medical conditions that render a
16child who is enrolled in the pediatric medical assistance
17program recipient eligible for the pilot program under this
18Act. Such serious illnesses medical conditions shall include,
19but need not be limited to, the following:
20        (1) Cancer (i) for which there is no known effective
21    treatment, (ii) that does not respond to conventional
22    protocol, (iii) that has progressed to an advanced stage,
23    or (iv) where toxicities or other complications limit
24    prohibit the administration of curative therapies.
25        (2) End-stage lung disease, including but not limited
26    to cystic fibrosis, that results in dependence on



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1    technology, such as mechanical ventilation.
2        (3) Severe neurological conditions, including, but not
3    limited to, hypoxic ischemic encephalopathy, acute brain
4    injury, brain infections and inflammatory diseases, or
5    irreversible severe alteration of mental status, with one
6    of the following co-morbidities: (i) intractable seizures
7    or (ii) brainstem failure to control breathing or other
8    automatic physiologic functions.
9        (4) Degenerative neuromuscular conditions, including,
10    but not limited to, spinal muscular atrophy, Type I or II,
11    or Duchenne Muscular Dystrophy, requiring technological
12    support.
13        (5) Genetic syndromes, such as, but not limited to,
14    Trisomy 13 or 18, where the child has substantial
15    neurocognitive disability (i) it is more likely than not
16    that the child will not live past 2 years of age or (ii)
17    the child is severely compromised with no expectation of
18    long-term survival.
19        (6) Congenital or acquired end-stage heart disease,
20    including but not limited to the following: (i) single
21    ventricle disorders, including hypoplastic left heart
22    syndrome; (ii) total anomalous pulmonary venous return,
23    not suitable for curative surgical treatment; and (iii)
24    heart muscle disorders (cardiomyopathies) without adequate
25    medical or surgical treatments available.
26        (7) End-stage liver disease where (i) transplant is



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1    not a viable option or (ii) transplant rejection or
2    failure has occurred.
3        (8) End-stage kidney failure where (i) transplant is
4    not a viable option or (ii) transplant rejection or
5    failure has occurred.
6        (9) Metabolic or biochemical disorders, including, but
7    not limited to, mitochondrial disease, leukodystrophies,
8    Tay-Sachs disease, or Lesch-Nyhan syndrome where (i) no
9    suitable therapies exist or (ii) available treatments,
10    including stem cell ("bone marrow") transplant, have
11    failed.
12        (10) Congenital or acquired diseases of the
13    gastrointestinal system, such as "short bowel syndrome",
14    where (i) transplant is not a viable option or (ii)
15    transplant rejection or failure has occurred.
16        (11) Congenital skin disorders, including but not
17    limited to epidermolysis bullosa, where no suitable
18    treatment exists.
19        (12) Any other serious illness that the Department, in
20    consultation with interested stakeholders, determines to
21    be appropriate.
22    The definition of a serious illness life-limiting medical
23condition shall not include a definitive time period due to
24the difficulty and challenges of prognosticating life
25expectancy in children.
26(Source: P.A. 96-1078, eff. 7-16-10.)



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1    (305 ILCS 60/30)
2    Sec. 30. Authorized providers. Providers authorized to
3deliver services under the pilot waiver program shall include
4licensed hospice agencies or home health agencies licensed to
5provide hospice care or entities with demonstrated expertise
6in pediatric palliative care and will be subject to further
7criteria developed by the Department, in consultation with
8interested stakeholders, for provider participation. At a
9minimum, the participating provider must house a pediatric
10interdisciplinary team that includes: (i) a physician, acting
11as the program medical director, who is board certified or
12board eligible in pediatrics or hospice and palliative
13medicine; (ii) a registered nurse; and (iii) a licensed social
14worker with a background in pediatric care a pediatric medical
15director, a nurse, and a licensed social worker. All members
16of the pediatric interdisciplinary team must meet criteria the
17Department may establish by rule, including demonstrated
18expertise in pediatric palliative care. submit to the
19Department proof of pediatric End-of-Life Nursing Education
20Curriculum (Pediatric ELNEC Training) or an equivalent.
21(Source: P.A. 96-1078, eff. 7-16-10.)
22    (305 ILCS 60/35)
23    Sec. 35. Interdisciplinary team; services. Subject to
24federal approval for matching funds, the reimbursable services



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1offered under the pilot program shall be provided by an
2interdisciplinary team, operating under the direction of a
3program pediatric medical director, and shall include, but not
4be limited to, the following:
5        (1) Nursing Pediatric nursing for pain and symptom
6    management.
7        (2) Expressive therapies (such as music or and art
8    therapies) for age-appropriate counseling.
9        (3) Client and family counseling (provided by a
10    licensed social worker, licensed professional counselor,
11    child life specialist, or non-denominational chaplain or
12    spiritual counselor).
13        (4) Respite care.
14        (5) Bereavement services.
15        (6) Case management.
16        (7) Any other services that the Department determines
17    to be appropriate.
18(Source: P.A. 96-1078, eff. 7-16-10.)
19    (305 ILCS 60/37 new)
20    Sec. 37. Medical assistance program standards for
21pediatric palliative care services. The Department, in
22consultation with interested stakeholders, shall establish
23standards for the provision of pediatric palliative care
24services under the medical assistance program under Article V
25of the Illinois Public Aid Code. The Department shall



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1establish standards for and provide technical assistance to
2managed care organizations, as defined in Section 5-30.1 of
3the Illinois Public Aid Code, to ensure the delivery of
4pediatric palliative care services to qualifying children.
5    (305 ILCS 60/40)
6    Sec. 40. Administration.
7    (a) The Department shall oversee the administration of the
8pilot program. The Department, in consultation with interested
9stakeholders, shall determine the appropriate process for
10review of referrals and enrollment of qualifying children
12    (b) The Department shall appoint an individual or entity
13to serve as program case manager or an alternative position to
14assess level-of-care and target-population criteria for the
15pilot program. The Department shall ensure that the individual
16or entity meets the criteria for demonstrated expertise in
17pediatric palliative care that the Department, in consultation
18with interested stakeholders, may establish by rule receives
19pediatric End-of-Life Nursing Education Curriculum (Pediatric
20ELNEC Training) or an equivalent to become familiarized with
21the unique needs and difficulties facing this population. The
22process for review of referrals and enrollment of qualifying
23children participants shall not include unnecessary delays and
24shall reflect the fact that treatment of pain and other
25distressing symptoms represents an urgent need for children



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1with a serious illness life-limiting medical conditions. The
2process shall also acknowledge that children with a serious
3illness life-limiting medical conditions and their families
4require holistic and seamless care.
5(Source: P.A. 96-1078, eff. 7-16-10.)
6    (305 ILCS 60/45)
7    Sec. 45. Report. Period of pilot program. After the
8program has been in place for 3 years, the Department shall
9prepare a report for the General Assembly concerning the
10program's outcomes effectiveness and shall also make
11recommendations for program improvement, including, but not
12limited to, the appropriateness of those serious illnesses
13that render a child who is enrolled in the medical assistance
14program eligible for the program as defined in subsection (b)
15of Section 25 and the necessary services needed to ensure
16high-quality care for qualifying children and their families.
17    (a) The program implemented under this Act shall be
18considered a pilot program for 3 years following the date of
19program implementation or, if the pilot program is created
20utilizing a waiver authority, until the waiver that includes
21the services provided under the program undergoes the
22federally mandated renewal process.
23    (b) During the period of time that the waiver program is
24considered a pilot program, pediatric palliative care shall be
25included in the issues reviewed by the Hospice and Palliative



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1Care Advisory Board. The Board shall make recommendations
2regarding changes or improvements to the program, including
3but not limited to advisement on potential expansion of the
4potentially life-limiting medical conditions as defined in
5subsection (b) of Section 25.
6    (c) At the end of the 3-year pilot program, the Department
7shall prepare a report for the General Assembly concerning the
8program's outcomes effectiveness and shall also make
9recommendations for program improvement, including, but not
10limited to, the appropriateness of the potentially
11life-limiting medical conditions as defined in subsection (b)
12of Section 25.
13(Source: P.A. 96-1078, eff. 7-16-10.)
14    (305 ILCS 60/3 rep.)
15    Section 10. The Pediatric Palliative Care Act is amended
16by repealing Section 3.".