Full Text of SB1437 98th General Assembly
SB1437 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB1437 Introduced 2/6/2013, by Sen. David Koehler SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/5-5 | from Ch. 23, par. 5-5 | 305 ILCS 5/5-5f | |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that one preventive dental visit a year shall be covered under the medical assistance program for pregnant women who are eligible for assistance. Removes a provision limiting adult dental services to emergencies. Effective July 1, 2013.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Sections 5-5 and 5-5f as follows: | 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing home, | 16 | | or elsewhere; (6) medical care, or any
other type of remedial | 17 | | care furnished by licensed practitioners; (7)
home health care | 18 | | services; (8) private duty nursing service; (9) clinic
| 19 | | services; (10) dental services, including prevention and | 20 | | treatment of periodontal disease and dental caries disease for | 21 | | pregnant women, provided by an individual licensed to practice | 22 | | dentistry or dental surgery; for purposes of this item (10), | 23 | | "dental services" means diagnostic, preventive, or corrective |
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| 1 | | procedures provided by or under the supervision of a dentist in | 2 | | the practice of his or her profession; (11) physical therapy | 3 | | and related
services; (12) prescribed drugs, dentures, and | 4 | | prosthetic devices; and
eyeglasses prescribed by a physician | 5 | | skilled in the diseases of the eye,
or by an optometrist, | 6 | | whichever the person may select; (13) other
diagnostic, | 7 | | screening, preventive, and rehabilitative services, including | 8 | | to ensure that the individual's need for intervention or | 9 | | treatment of mental disorders or substance use disorders or | 10 | | co-occurring mental health and substance use disorders is | 11 | | determined using a uniform screening, assessment, and | 12 | | evaluation process inclusive of criteria, for children and | 13 | | adults; for purposes of this item (13), a uniform screening, | 14 | | assessment, and evaluation process refers to a process that | 15 | | includes an appropriate evaluation and, as warranted, a | 16 | | referral; "uniform" does not mean the use of a singular | 17 | | instrument, tool, or process that all must utilize; (14)
| 18 | | transportation and such other expenses as may be necessary; | 19 | | (15) medical
treatment of sexual assault survivors, as defined | 20 | | in
Section 1a of the Sexual Assault Survivors Emergency | 21 | | Treatment Act, for
injuries sustained as a result of the sexual | 22 | | assault, including
examinations and laboratory tests to | 23 | | discover evidence which may be used in
criminal proceedings | 24 | | arising from the sexual assault; (16) the
diagnosis and | 25 | | treatment of sickle cell anemia; and (17)
any other medical | 26 | | care, and any other type of remedial care recognized
under the |
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| 1 | | laws of this State, but not including abortions, or induced
| 2 | | miscarriages or premature births, unless, in the opinion of a | 3 | | physician,
such procedures are necessary for the preservation | 4 | | of the life of the
woman seeking such treatment, or except an | 5 | | induced premature birth
intended to produce a live viable child | 6 | | and such procedure is necessary
for the health of the mother or | 7 | | her unborn child. The Illinois Department,
by rule, shall | 8 | | prohibit any physician from providing medical assistance
to | 9 | | anyone eligible therefor under this Code where such physician | 10 | | has been
found guilty of performing an abortion procedure in a | 11 | | wilful and wanton
manner upon a woman who was not pregnant at | 12 | | the time such abortion
procedure was performed. The term "any | 13 | | other type of remedial care" shall
include nursing care and | 14 | | nursing home service for persons who rely on
treatment by | 15 | | spiritual means alone through prayer for healing.
| 16 | | Notwithstanding any other provision of this Code, one | 17 | | preventive dental visit a year shall be covered under the | 18 | | medical assistance program under this Article for pregnant | 19 | | women who are eligible for assistance under this Article. | 20 | | Notwithstanding any other provision of this Section, a | 21 | | comprehensive
tobacco use cessation program that includes | 22 | | purchasing prescription drugs or
prescription medical devices | 23 | | approved by the Food and Drug Administration shall
be covered | 24 | | under the medical assistance
program under this Article for | 25 | | persons who are otherwise eligible for
assistance under this | 26 | | Article.
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| 1 | | Notwithstanding any other provision of this Code, the | 2 | | Illinois
Department may not require, as a condition of payment | 3 | | for any laboratory
test authorized under this Article, that a | 4 | | physician's handwritten signature
appear on the laboratory | 5 | | test order form. The Illinois Department may,
however, impose | 6 | | other appropriate requirements regarding laboratory test
order | 7 | | documentation.
| 8 | | On and after July 1, 2012, the Department of Healthcare and | 9 | | Family Services may provide the following services to
persons
| 10 | | eligible for assistance under this Article who are | 11 | | participating in
education, training or employment programs | 12 | | operated by the Department of Human
Services as successor to | 13 | | the Department of Public Aid:
| 14 | | (1) dental services provided by or under the | 15 | | supervision of a dentist; and
| 16 | | (2) eyeglasses prescribed by a physician skilled in the | 17 | | diseases of the
eye, or by an optometrist, whichever the | 18 | | person may select.
| 19 | | Notwithstanding any other provision of this Code and | 20 | | subject to federal approval, the Department may adopt rules to | 21 | | allow a dentist who is volunteering his or her service at no | 22 | | cost to render dental services through an enrolled | 23 | | not-for-profit health clinic without the dentist personally | 24 | | enrolling as a participating provider in the medical assistance | 25 | | program. A not-for-profit health clinic shall include a public | 26 | | health clinic or Federally Qualified Health Center or other |
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| 1 | | enrolled provider, as determined by the Department, through | 2 | | which dental services covered under this Section are performed. | 3 | | The Department shall establish a process for payment of claims | 4 | | for reimbursement for covered dental services rendered under | 5 | | this provision. | 6 | | The Illinois Department, by rule, may distinguish and | 7 | | classify the
medical services to be provided only in accordance | 8 | | with the classes of
persons designated in Section 5-2.
| 9 | | The Department of Healthcare and Family Services must | 10 | | provide coverage and reimbursement for amino acid-based | 11 | | elemental formulas, regardless of delivery method, for the | 12 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 13 | | short bowel syndrome when the prescribing physician has issued | 14 | | a written order stating that the amino acid-based elemental | 15 | | formula is medically necessary.
| 16 | | The Illinois Department shall authorize the provision of, | 17 | | and shall
authorize payment for, screening by low-dose | 18 | | mammography for the presence of
occult breast cancer for women | 19 | | 35 years of age or older who are eligible
for medical | 20 | | assistance under this Article, as follows: | 21 | | (A) A baseline
mammogram for women 35 to 39 years of | 22 | | age.
| 23 | | (B) An annual mammogram for women 40 years of age or | 24 | | older. | 25 | | (C) A mammogram at the age and intervals considered | 26 | | medically necessary by the woman's health care provider for |
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| 1 | | women under 40 years of age and having a family history of | 2 | | breast cancer, prior personal history of breast cancer, | 3 | | positive genetic testing, or other risk factors. | 4 | | (D) A comprehensive ultrasound screening of an entire | 5 | | breast or breasts if a mammogram demonstrates | 6 | | heterogeneous or dense breast tissue, when medically | 7 | | necessary as determined by a physician licensed to practice | 8 | | medicine in all of its branches. | 9 | | All screenings
shall
include a physical breast exam, | 10 | | instruction on self-examination and
information regarding the | 11 | | frequency of self-examination and its value as a
preventative | 12 | | tool. For purposes of this Section, "low-dose mammography" | 13 | | means
the x-ray examination of the breast using equipment | 14 | | dedicated specifically
for mammography, including the x-ray | 15 | | tube, filter, compression device,
and image receptor, with an | 16 | | average radiation exposure delivery
of less than one rad per | 17 | | breast for 2 views of an average size breast.
The term also | 18 | | includes digital mammography.
| 19 | | On and after January 1, 2012, providers participating in a | 20 | | quality improvement program approved by the Department shall be | 21 | | reimbursed for screening and diagnostic mammography at the same | 22 | | rate as the Medicare program's rates, including the increased | 23 | | reimbursement for digital mammography. | 24 | | The Department shall convene an expert panel including | 25 | | representatives of hospitals, free-standing mammography | 26 | | facilities, and doctors, including radiologists, to establish |
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| 1 | | quality standards. | 2 | | Subject to federal approval, the Department shall | 3 | | establish a rate methodology for mammography at federally | 4 | | qualified health centers and other encounter-rate clinics. | 5 | | These clinics or centers may also collaborate with other | 6 | | hospital-based mammography facilities. | 7 | | The Department shall establish a methodology to remind | 8 | | women who are age-appropriate for screening mammography, but | 9 | | who have not received a mammogram within the previous 18 | 10 | | months, of the importance and benefit of screening mammography. | 11 | | The Department shall establish a performance goal for | 12 | | primary care providers with respect to their female patients | 13 | | over age 40 receiving an annual mammogram. This performance | 14 | | goal shall be used to provide additional reimbursement in the | 15 | | form of a quality performance bonus to primary care providers | 16 | | who meet that goal. | 17 | | The Department shall devise a means of case-managing or | 18 | | patient navigation for beneficiaries diagnosed with breast | 19 | | cancer. This program shall initially operate as a pilot program | 20 | | in areas of the State with the highest incidence of mortality | 21 | | related to breast cancer. At least one pilot program site shall | 22 | | be in the metropolitan Chicago area and at least one site shall | 23 | | be outside the metropolitan Chicago area. An evaluation of the | 24 | | pilot program shall be carried out measuring health outcomes | 25 | | and cost of care for those served by the pilot program compared | 26 | | to similarly situated patients who are not served by the pilot |
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| 1 | | program. | 2 | | Any medical or health care provider shall immediately | 3 | | recommend, to
any pregnant woman who is being provided prenatal | 4 | | services and is suspected
of drug abuse or is addicted as | 5 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 6 | | Act, referral to a local substance abuse treatment provider
| 7 | | licensed by the Department of Human Services or to a licensed
| 8 | | hospital which provides substance abuse treatment services. | 9 | | The Department of Healthcare and Family Services
shall assure | 10 | | coverage for the cost of treatment of the drug abuse or
| 11 | | addiction for pregnant recipients in accordance with the | 12 | | Illinois Medicaid
Program in conjunction with the Department of | 13 | | Human Services.
| 14 | | All medical providers providing medical assistance to | 15 | | pregnant women
under this Code shall receive information from | 16 | | the Department on the
availability of services under the Drug | 17 | | Free Families with a Future or any
comparable program providing | 18 | | case management services for addicted women,
including | 19 | | information on appropriate referrals for other social services
| 20 | | that may be needed by addicted women in addition to treatment | 21 | | for addiction.
| 22 | | The Illinois Department, in cooperation with the | 23 | | Departments of Human
Services (as successor to the Department | 24 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 25 | | public awareness campaign, may
provide information concerning | 26 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
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| 1 | | health care, and other pertinent programs directed at
reducing | 2 | | the number of drug-affected infants born to recipients of | 3 | | medical
assistance.
| 4 | | Neither the Department of Healthcare and Family Services | 5 | | nor the Department of Human
Services shall sanction the | 6 | | recipient solely on the basis of
her substance abuse.
| 7 | | The Illinois Department shall establish such regulations | 8 | | governing
the dispensing of health services under this Article | 9 | | as it shall deem
appropriate. The Department
should
seek the | 10 | | advice of formal professional advisory committees appointed by
| 11 | | the Director of the Illinois Department for the purpose of | 12 | | providing regular
advice on policy and administrative matters, | 13 | | information dissemination and
educational activities for | 14 | | medical and health care providers, and
consistency in | 15 | | procedures to the Illinois Department.
| 16 | | The Illinois Department may develop and contract with | 17 | | Partnerships of
medical providers to arrange medical services | 18 | | for persons eligible under
Section 5-2 of this Code. | 19 | | Implementation of this Section may be by
demonstration projects | 20 | | in certain geographic areas. The Partnership shall
be | 21 | | represented by a sponsor organization. The Department, by rule, | 22 | | shall
develop qualifications for sponsors of Partnerships. | 23 | | Nothing in this
Section shall be construed to require that the | 24 | | sponsor organization be a
medical organization.
| 25 | | The sponsor must negotiate formal written contracts with | 26 | | medical
providers for physician services, inpatient and |
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| 1 | | outpatient hospital care,
home health services, treatment for | 2 | | alcoholism and substance abuse, and
other services determined | 3 | | necessary by the Illinois Department by rule for
delivery by | 4 | | Partnerships. Physician services must include prenatal and
| 5 | | obstetrical care. The Illinois Department shall reimburse | 6 | | medical services
delivered by Partnership providers to clients | 7 | | in target areas according to
provisions of this Article and the | 8 | | Illinois Health Finance Reform Act,
except that:
| 9 | | (1) Physicians participating in a Partnership and | 10 | | providing certain
services, which shall be determined by | 11 | | the Illinois Department, to persons
in areas covered by the | 12 | | Partnership may receive an additional surcharge
for such | 13 | | services.
| 14 | | (2) The Department may elect to consider and negotiate | 15 | | financial
incentives to encourage the development of | 16 | | Partnerships and the efficient
delivery of medical care.
| 17 | | (3) Persons receiving medical services through | 18 | | Partnerships may receive
medical and case management | 19 | | services above the level usually offered
through the | 20 | | medical assistance program.
| 21 | | Medical providers shall be required to meet certain | 22 | | qualifications to
participate in Partnerships to ensure the | 23 | | delivery of high quality medical
services. These | 24 | | qualifications shall be determined by rule of the Illinois
| 25 | | Department and may be higher than qualifications for | 26 | | participation in the
medical assistance program. Partnership |
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| 1 | | sponsors may prescribe reasonable
additional qualifications | 2 | | for participation by medical providers, only with
the prior | 3 | | written approval of the Illinois Department.
| 4 | | Nothing in this Section shall limit the free choice of | 5 | | practitioners,
hospitals, and other providers of medical | 6 | | services by clients.
In order to ensure patient freedom of | 7 | | choice, the Illinois Department shall
immediately promulgate | 8 | | all rules and take all other necessary actions so that
provided | 9 | | services may be accessed from therapeutically certified | 10 | | optometrists
to the full extent of the Illinois Optometric | 11 | | Practice Act of 1987 without
discriminating between service | 12 | | providers.
| 13 | | The Department shall apply for a waiver from the United | 14 | | States Health
Care Financing Administration to allow for the | 15 | | implementation of
Partnerships under this Section.
| 16 | | The Illinois Department shall require health care | 17 | | providers to maintain
records that document the medical care | 18 | | and services provided to recipients
of Medical Assistance under | 19 | | this Article. Such records must be retained for a period of not | 20 | | less than 6 years from the date of service or as provided by | 21 | | applicable State law, whichever period is longer, except that | 22 | | if an audit is initiated within the required retention period | 23 | | then the records must be retained until the audit is completed | 24 | | and every exception is resolved. The Illinois Department shall
| 25 | | require health care providers to make available, when | 26 | | authorized by the
patient, in writing, the medical records in a |
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| 1 | | timely fashion to other
health care providers who are treating | 2 | | or serving persons eligible for
Medical Assistance under this | 3 | | Article. All dispensers of medical services
shall be required | 4 | | to maintain and retain business and professional records
| 5 | | sufficient to fully and accurately document the nature, scope, | 6 | | details and
receipt of the health care provided to persons | 7 | | eligible for medical
assistance under this Code, in accordance | 8 | | with regulations promulgated by
the Illinois Department. The | 9 | | rules and regulations shall require that proof
of the receipt | 10 | | of prescription drugs, dentures, prosthetic devices and
| 11 | | eyeglasses by eligible persons under this Section accompany | 12 | | each claim
for reimbursement submitted by the dispenser of such | 13 | | medical services.
No such claims for reimbursement shall be | 14 | | approved for payment by the Illinois
Department without such | 15 | | proof of receipt, unless the Illinois Department
shall have put | 16 | | into effect and shall be operating a system of post-payment
| 17 | | audit and review which shall, on a sampling basis, be deemed | 18 | | adequate by
the Illinois Department to assure that such drugs, | 19 | | dentures, prosthetic
devices and eyeglasses for which payment | 20 | | is being made are actually being
received by eligible | 21 | | recipients. Within 90 days after the effective date of
this | 22 | | amendatory Act of 1984, the Illinois Department shall establish | 23 | | a
current list of acquisition costs for all prosthetic devices | 24 | | and any
other items recognized as medical equipment and | 25 | | supplies reimbursable under
this Article and shall update such | 26 | | list on a quarterly basis, except that
the acquisition costs of |
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| 1 | | all prescription drugs shall be updated no
less frequently than | 2 | | every 30 days as required by Section 5-5.12.
| 3 | | The rules and regulations of the Illinois Department shall | 4 | | require
that a written statement including the required opinion | 5 | | of a physician
shall accompany any claim for reimbursement for | 6 | | abortions, or induced
miscarriages or premature births. This | 7 | | statement shall indicate what
procedures were used in providing | 8 | | such medical services.
| 9 | | The Illinois Department shall require all dispensers of | 10 | | medical
services, other than an individual practitioner or | 11 | | group of practitioners,
desiring to participate in the Medical | 12 | | Assistance program
established under this Article to disclose | 13 | | all financial, beneficial,
ownership, equity, surety or other | 14 | | interests in any and all firms,
corporations, partnerships, | 15 | | associations, business enterprises, joint
ventures, agencies, | 16 | | institutions or other legal entities providing any
form of | 17 | | health care services in this State under this Article.
| 18 | | The Illinois Department may require that all dispensers of | 19 | | medical
services desiring to participate in the medical | 20 | | assistance program
established under this Article disclose, | 21 | | under such terms and conditions as
the Illinois Department may | 22 | | by rule establish, all inquiries from clients
and attorneys | 23 | | regarding medical bills paid by the Illinois Department, which
| 24 | | inquiries could indicate potential existence of claims or liens | 25 | | for the
Illinois Department.
| 26 | | Enrollment of a vendor
shall be
subject to a provisional |
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| 1 | | period and shall be conditional for one year. During the period | 2 | | of conditional enrollment, the Department may
terminate the | 3 | | vendor's eligibility to participate in, or may disenroll the | 4 | | vendor from, the medical assistance
program without cause. | 5 | | Unless otherwise specified, such termination of eligibility or | 6 | | disenrollment is not subject to the
Department's hearing | 7 | | process.
However, a disenrolled vendor may reapply without | 8 | | penalty.
| 9 | | The Department has the discretion to limit the conditional | 10 | | enrollment period for vendors based upon category of risk of | 11 | | the vendor. | 12 | | Prior to enrollment and during the conditional enrollment | 13 | | period in the medical assistance program, all vendors shall be | 14 | | subject to enhanced oversight, screening, and review based on | 15 | | the risk of fraud, waste, and abuse that is posed by the | 16 | | category of risk of the vendor. The Illinois Department shall | 17 | | establish the procedures for oversight, screening, and review, | 18 | | which may include, but need not be limited to: criminal and | 19 | | financial background checks; fingerprinting; license, | 20 | | certification, and authorization verifications; unscheduled or | 21 | | unannounced site visits; database checks; prepayment audit | 22 | | reviews; audits; payment caps; payment suspensions; and other | 23 | | screening as required by federal or State law. | 24 | | The Department shall define or specify the following: (i) | 25 | | by provider notice, the "category of risk of the vendor" for | 26 | | each type of vendor, which shall take into account the level of |
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| 1 | | screening applicable to a particular category of vendor under | 2 | | federal law and regulations; (ii) by rule or provider notice, | 3 | | the maximum length of the conditional enrollment period for | 4 | | each category of risk of the vendor; and (iii) by rule, the | 5 | | hearing rights, if any, afforded to a vendor in each category | 6 | | of risk of the vendor that is terminated or disenrolled during | 7 | | the conditional enrollment period. | 8 | | To be eligible for payment consideration, a vendor's | 9 | | payment claim or bill, either as an initial claim or as a | 10 | | resubmitted claim following prior rejection, must be received | 11 | | by the Illinois Department, or its fiscal intermediary, no | 12 | | later than 180 days after the latest date on the claim on which | 13 | | medical goods or services were provided, with the following | 14 | | exceptions: | 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 | | For claims for services rendered during a period for which | 2 | | a recipient received retroactive eligibility, claims must be | 3 | | filed within 180 days after the Department determines the | 4 | | applicant is eligible. For claims for which the Illinois | 5 | | Department is not the primary payer, claims must be submitted | 6 | | to the Illinois Department within 180 days after the final | 7 | | adjudication by the primary payer. | 8 | | In the case of long term care facilities, admission | 9 | | documents shall be submitted within 30 days of an admission to | 10 | | the facility through the Medical Electronic Data Interchange | 11 | | (MEDI) or the Recipient Eligibility Verification (REV) System, | 12 | | or shall be submitted directly to the Department of Human | 13 | | Services using required admission forms. Confirmation numbers | 14 | | assigned to an accepted transaction shall be retained by a | 15 | | facility to verify timely submittal. Once an admission | 16 | | transaction has been completed, all resubmitted claims | 17 | | following prior rejection are subject to receipt no later than | 18 | | 180 days after the admission transaction has been completed. | 19 | | Claims that are not submitted and received in compliance | 20 | | with the foregoing requirements shall not be eligible for | 21 | | payment under the medical assistance program, and the State | 22 | | shall have no liability for payment of those claims. | 23 | | To the extent consistent with applicable information and | 24 | | privacy, security, and disclosure laws, State and federal | 25 | | agencies and departments shall provide the Illinois Department | 26 | | access to confidential and other information and data necessary |
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| 1 | | to perform eligibility and payment verifications and other | 2 | | Illinois Department functions. This includes, but is not | 3 | | limited to: information pertaining to licensure; | 4 | | certification; earnings; immigration status; citizenship; wage | 5 | | reporting; unearned and earned income; pension income; | 6 | | employment; supplemental security income; social security | 7 | | numbers; National Provider Identifier (NPI) numbers; the | 8 | | National Practitioner Data Bank (NPDB); program and agency | 9 | | exclusions; taxpayer identification numbers; tax delinquency; | 10 | | corporate information; and death records. | 11 | | The Illinois Department shall enter into agreements with | 12 | | State agencies and departments, and is authorized to enter into | 13 | | agreements with federal agencies and departments, under which | 14 | | such agencies and departments shall share data necessary for | 15 | | medical assistance program integrity functions and oversight. | 16 | | The Illinois Department shall develop, in cooperation with | 17 | | other State departments and agencies, and in compliance with | 18 | | applicable federal laws and regulations, appropriate and | 19 | | effective methods to share such data. At a minimum, and to the | 20 | | extent necessary to provide data sharing, the Illinois | 21 | | Department shall enter into agreements with State agencies and | 22 | | departments, and is authorized to enter into agreements with | 23 | | federal agencies and departments, including but not limited to: | 24 | | the Secretary of State; the Department of Revenue; the | 25 | | Department of Public Health; the Department of Human Services; | 26 | | and the Department of Financial and Professional Regulation. |
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| 1 | | Beginning in fiscal year 2013, the Illinois Department | 2 | | shall set forth a request for information to identify the | 3 | | benefits of a pre-payment, post-adjudication, and post-edit | 4 | | claims system with the goals of streamlining claims processing | 5 | | and provider reimbursement, reducing the number of pending or | 6 | | rejected claims, and helping to ensure a more transparent | 7 | | adjudication process through the utilization of: (i) provider | 8 | | data verification and provider screening technology; and (ii) | 9 | | clinical code editing; and (iii) pre-pay, pre- or | 10 | | post-adjudicated predictive modeling with an integrated case | 11 | | management system with link analysis. Such a request for | 12 | | information shall not be considered as a request for proposal | 13 | | or as an obligation on the part of the Illinois Department to | 14 | | take any action or acquire any products or services. | 15 | | The Illinois Department shall establish policies, | 16 | | procedures,
standards and criteria by rule for the acquisition, | 17 | | repair and replacement
of orthotic and prosthetic devices and | 18 | | durable medical equipment. Such
rules shall provide, but not be | 19 | | limited to, the following services: (1)
immediate repair or | 20 | | replacement of such devices by recipients; and (2) rental, | 21 | | lease, purchase or lease-purchase of
durable medical equipment | 22 | | in a cost-effective manner, taking into
consideration the | 23 | | recipient's medical prognosis, the extent of the
recipient's | 24 | | needs, and the requirements and costs for maintaining such
| 25 | | equipment. Subject to prior approval, such rules shall enable a | 26 | | recipient to temporarily acquire and
use alternative or |
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| 1 | | substitute devices or equipment pending repairs or
| 2 | | replacements of any device or equipment previously authorized | 3 | | for such
recipient by the Department.
| 4 | | The Department shall execute, relative to the nursing home | 5 | | prescreening
project, written inter-agency agreements with the | 6 | | Department of Human
Services and the Department on Aging, to | 7 | | effect the following: (i) intake
procedures and common | 8 | | eligibility criteria for those persons who are receiving
| 9 | | non-institutional services; and (ii) the establishment and | 10 | | development of
non-institutional services in areas of the State | 11 | | where they are not currently
available or are undeveloped; and | 12 | | (iii) notwithstanding any other provision of law, subject to | 13 | | federal approval, on and after July 1, 2012, an increase in the | 14 | | determination of need (DON) scores from 29 to 37 for applicants | 15 | | for institutional and home and community-based long term care; | 16 | | if and only if federal approval is not granted, the Department | 17 | | may, in conjunction with other affected agencies, implement | 18 | | utilization controls or changes in benefit packages to | 19 | | effectuate a similar savings amount for this population; and | 20 | | (iv) no later than July 1, 2013, minimum level of care | 21 | | eligibility criteria for institutional and home and | 22 | | community-based long term care. In order to select the minimum | 23 | | level of care eligibility criteria, the Governor shall | 24 | | establish a workgroup that includes affected agency | 25 | | representatives and stakeholders representing the | 26 | | institutional and home and community-based long term care |
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| 1 | | interests. This Section shall not restrict the Department from | 2 | | implementing lower level of care eligibility criteria for | 3 | | community-based services in circumstances where federal | 4 | | approval has been granted.
| 5 | | The Illinois Department shall develop and operate, in | 6 | | cooperation
with other State Departments and agencies and in | 7 | | compliance with
applicable federal laws and regulations, | 8 | | appropriate and effective
systems of health care evaluation and | 9 | | programs for monitoring of
utilization of health care services | 10 | | and facilities, as it affects
persons eligible for medical | 11 | | assistance under this Code.
| 12 | | The Illinois Department shall report annually to the | 13 | | General Assembly,
no later than the second Friday in April of | 14 | | 1979 and each year
thereafter, in regard to:
| 15 | | (a) actual statistics and trends in utilization of | 16 | | medical services by
public aid recipients;
| 17 | | (b) actual statistics and trends in the provision of | 18 | | the various medical
services by medical vendors;
| 19 | | (c) current rate structures and proposed changes in | 20 | | those rate structures
for the various medical vendors; and
| 21 | | (d) efforts at utilization review and control by the | 22 | | Illinois Department.
| 23 | | The period covered by each report shall be the 3 years | 24 | | ending on the June
30 prior to the report. The report shall | 25 | | include suggested legislation
for consideration by the General | 26 | | Assembly. The filing of one copy of the
report with the |
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| 1 | | Speaker, one copy with the Minority Leader and one copy
with | 2 | | the Clerk of the House of Representatives, one copy with the | 3 | | President,
one copy with the Minority Leader and one copy with | 4 | | the Secretary of the
Senate, one copy with the Legislative | 5 | | Research Unit, and such additional
copies
with the State | 6 | | Government Report Distribution Center for the General
Assembly | 7 | | as is required under paragraph (t) of Section 7 of the State
| 8 | | Library Act shall be deemed sufficient to comply with this | 9 | | Section.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | On and after July 1, 2012, the Department shall reduce any | 17 | | rate of reimbursement for services or other payments or alter | 18 | | any methodologies authorized by this Code to reduce any rate of | 19 | | reimbursement for services or other payments in accordance with | 20 | | Section 5-5e. | 21 | | (Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926, | 22 | | eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638, | 23 | | eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12; | 24 | | revised 9-20-12.) | 25 | | (305 ILCS 5/5-5f) |
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| 1 | | Sec. 5-5f. Elimination and limitations of medical | 2 | | assistance services. Notwithstanding any other provision of | 3 | | this Code to the contrary, on and after July 1, 2012: | 4 | | (a) The following services shall no longer be a covered | 5 | | service available under this Code: group psychotherapy for | 6 | | residents of any facility licensed under the Nursing Home Care | 7 | | Act or the Specialized Mental Health Rehabilitation Act; and | 8 | | adult chiropractic services. | 9 | | (b) The Department shall place the following limitations on | 10 | | services: (i) the Department shall limit adult eyeglasses to | 11 | | one pair every 2 years; (ii) the Department shall set an annual | 12 | | limit of a maximum of 20 visits for each of the following | 13 | | services: adult speech, hearing, and language therapy | 14 | | services, adult occupational therapy services, and physical | 15 | | therapy services; (iii) the Department shall limit podiatry | 16 | | services to individuals with diabetes; (iv) the Department | 17 | | shall pay for caesarean sections at the normal vaginal delivery | 18 | | rate unless a caesarean section was medically necessary; (v) | 19 | | (blank) the Department shall limit adult dental services to | 20 | | emergencies ; and (vi) effective July 1, 2012, the Department | 21 | | shall place limitations and require concurrent review on every | 22 | | inpatient detoxification stay to prevent repeat admissions to | 23 | | any hospital for detoxification within 60 days of a previous | 24 | | inpatient detoxification stay. The Department shall convene a | 25 | | workgroup of hospitals, substance abuse providers, care | 26 | | coordination entities, managed care plans, and other |
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| 1 | | stakeholders to develop recommendations for quality standards, | 2 | | diversion to other settings, and admission criteria for | 3 | | patients who need inpatient detoxification. | 4 | | (c) The Department shall require prior approval of the | 5 | | following services: wheelchair repairs, regardless of the cost | 6 | | of the repairs, coronary artery bypass graft, and bariatric | 7 | | surgery consistent with Medicare standards concerning patient | 8 | | responsibility. The wholesale cost of power wheelchairs shall | 9 | | be actual acquisition cost including all discounts. | 10 | | (d) The Department shall establish benchmarks for | 11 | | hospitals to measure and align payments to reduce potentially | 12 | | preventable hospital readmissions, inpatient complications, | 13 | | and unnecessary emergency room visits. In doing so, the | 14 | | Department shall consider items, including, but not limited to, | 15 | | historic and current acuity of care and historic and current | 16 | | trends in readmission. The Department shall publish | 17 | | provider-specific historical readmission data and anticipated | 18 | | potentially preventable targets 60 days prior to the start of | 19 | | the program. In the instance of readmissions, the Department | 20 | | shall adopt policies and rates of reimbursement for services | 21 | | and other payments provided under this Code to ensure that, by | 22 | | June 30, 2013, expenditures to hospitals are reduced by, at a | 23 | | minimum, $40,000,000. | 24 | | (e) The Department shall establish utilization controls | 25 | | for the hospice program such that it shall not pay for other | 26 | | care services when an individual is in hospice. |
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| 1 | | (f) For home health services, the Department shall require | 2 | | Medicare certification of providers participating in the | 3 | | program, implement the Medicare face-to-face encounter rule, | 4 | | and limit services to post-hospitalization. The Department | 5 | | shall require providers to implement auditable electronic | 6 | | service verification based on global positioning systems or | 7 | | other cost-effective technology. | 8 | | (g) For the Home Services Program operated by the | 9 | | Department of Human Services and the Community Care Program | 10 | | operated by the Department on Aging, the Department of Human | 11 | | Services, in cooperation with the Department on Aging, shall | 12 | | implement an electronic service verification based on global | 13 | | positioning systems or other cost-effective technology. | 14 | | (h) The Department shall not pay for hospital admissions | 15 | | when the claim indicates a hospital acquired condition that | 16 | | would cause Medicare to reduce its payment on the claim had the | 17 | | claim been submitted to Medicare, nor shall the Department pay | 18 | | for hospital admissions where a Medicare identified "never | 19 | | event" occurred. | 20 | | (i) The Department shall implement cost savings | 21 | | initiatives for advanced imaging services, cardiac imaging | 22 | | services, pain management services, and back surgery. Such | 23 | | initiatives shall be designed to achieve annual costs savings.
| 24 | | (Source: P.A. 97-689, eff. 6-14-12.)
| 25 | | Section 99. Effective date. This Act takes effect July 1, | 26 | | 2013.
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