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Public Act 099-0407
Public Act 0407 99TH GENERAL ASSEMBLY
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Public Act 099-0407
| | SB0054 Enrolled | LRB099 03946 MLM 23963 b |
|
| AN ACT concerning regulation.
| Be it enacted by the People of the State of Illinois,
| represented in the General Assembly:
| Section 5. The Illinois Insurance Code is amended by | changing Section 356g as follows:
| (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| Sec. 356g. Mammograms; mastectomies.
| (a) Every insurer shall provide in each group or individual
| policy, contract, or certificate of insurance issued or renewed | for persons
who are residents of this State, coverage for | screening by low-dose
mammography for all women 35 years of age | or older for the presence of
occult breast cancer within the | provisions of the policy, contract, or
certificate. The | coverage shall be as follows:
|
(1) A baseline mammogram for women 35 to 39 years of | age.
|
(2) An annual mammogram for women 40 years of age or | older.
| (3) A mammogram at the age and intervals considered | medically necessary by the woman's health care provider for | women under 40 years of age and having a family history of | breast cancer, prior personal history of breast cancer, | positive genetic testing, or other risk factors.
|
| (4) A comprehensive ultrasound screening of an entire | breast or breasts if a mammogram demonstrates | heterogeneous or dense breast tissue, when medically | necessary as determined by a physician licensed to practice | medicine in all of its branches.
| For purposes of this Section, "low-dose mammography"
means | the x-ray examination of the breast using equipment dedicated
| specifically for mammography, including the x-ray tube, | filter, compression
device, and image receptor, with radiation | exposure delivery of less than
1 rad per breast for 2 views of | an average size breast. The term also includes digital | mammography and includes breast tomosynthesis. As used in this | Section, the term "breast tomosynthesis" means a radiologic | procedure that involves the acquisition of projection images | over the stationary breast to produce cross-sectional digital | three-dimensional images of the breast.
| (a-5) Coverage as described by subsection (a) shall be | provided at no cost to the insured and shall not be applied to | an annual or lifetime maximum benefit. | (a-10) When health care services are available through | contracted providers and a person does not comply with plan | provisions specific to the use of contracted providers, the | requirements of subsection (a-5) are not applicable. When a | person does not comply with plan provisions specific to the use | of contracted providers, plan provisions specific to the use of | non-contracted providers must be applied without distinction |
| for coverage required by this Section and shall be at least as | favorable as for other radiological examinations covered by the | policy or contract. | (b) No policy of accident or health insurance that provides | for
the surgical procedure known as a mastectomy shall be | issued, amended,
delivered, or renewed in this State unless
| that coverage also provides for prosthetic devices
or | reconstructive surgery
incident to the mastectomy.
Coverage | for breast reconstruction in connection with a mastectomy shall
| include:
| (1) reconstruction of the breast upon which the | mastectomy has been
performed;
| (2) surgery and reconstruction of the other breast to | produce a
symmetrical appearance; and
| (3) prostheses and treatment for physical | complications at all stages of
mastectomy, including | lymphedemas.
| Care shall be determined in consultation with the attending | physician and the
patient.
The offered coverage for prosthetic | devices and
reconstructive surgery shall be subject to the | deductible and coinsurance
conditions applied to the | mastectomy, and all other terms and conditions
applicable to | other benefits. When a mastectomy is performed and there is
no | evidence of malignancy then the offered coverage may be limited | to the
provision of prosthetic devices and reconstructive | surgery to within 2
years after the date of the mastectomy. As |
| used in this Section,
"mastectomy" means the removal of all or | part of the breast for medically
necessary reasons, as | determined by a licensed physician.
| Written notice of the availability of coverage under this | Section shall be
delivered to the insured upon enrollment and | annually thereafter. An insurer
may not deny to an insured | eligibility, or continued eligibility, to enroll or
to renew | coverage under the terms of the plan solely for the purpose of
| avoiding the requirements of this Section. An insurer may not | penalize or
reduce or
limit the reimbursement of an attending | provider or provide incentives
(monetary or otherwise) to an | attending provider to induce the provider to
provide care to an | insured in a manner inconsistent with this Section.
| (c) Rulemaking authority to implement this amendatory Act | of the 95th General Assembly, if any, is conditioned on the | rules being adopted in accordance with all provisions of the | Illinois Administrative Procedure Act and all rules and | procedures of the Joint Committee on Administrative Rules; any | purported rule not so adopted, for whatever reason, is | unauthorized. | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 95-1045, eff. 3-27-09.)
| Section 10. The Health Maintenance Organization Act is | amended by changing Section 4-6.1 as follows:
|
| (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| Sec. 4-6.1. Mammograms; mastectomies.
| (a) Every contract or evidence of coverage
issued by a | Health Maintenance Organization for persons who are residents | of
this State shall contain coverage for screening by low-dose | mammography
for all women 35 years of age or older for the | presence of occult breast
cancer. The coverage shall be as | follows:
| (1) A baseline mammogram for women 35 to 39 years of | age.
| (2) An annual mammogram for women 40 years of age or | older.
| (3) A mammogram at the age and intervals considered | medically necessary by the woman's health care provider for | women under 40 years of age and having a family history of | breast cancer, prior personal history of breast cancer, | positive genetic testing, or other risk factors. | (4) A comprehensive ultrasound screening of an entire | breast or breasts if a mammogram demonstrates | heterogeneous or dense breast tissue, when medically | necessary as determined by a physician licensed to practice | medicine in all of its branches.
| For purposes of this Section, "low-dose mammography"
means | the x-ray examination of the breast using equipment dedicated
| specifically for mammography, including the x-ray tube, | filter, compression
device, and image receptor, with radiation |
| exposure delivery of less than 1
rad per breast for 2 views of | an average size breast. The term also includes digital | mammography and includes breast tomosynthesis. As used in this | Section, the term "breast tomosynthesis" means a radiologic | procedure that involves the acquisition of projection images | over the stationary breast to produce cross-sectional digital | three-dimensional images of the breast.
| (a-5) Coverage as described in subsection (a) shall be | provided at no cost to the enrollee and shall not be applied to | an annual or lifetime maximum benefit. | (b) No contract or evidence of coverage issued by a health | maintenance
organization that provides for the
surgical | procedure known as a mastectomy shall be issued, amended, | delivered,
or renewed in this State on or after the effective | date of this amendatory Act
of the 92nd General Assembly unless | that coverage also provides for prosthetic
devices or | reconstructive surgery incident to the mastectomy, providing | that
the mastectomy is performed after the effective date of | this amendatory Act.
Coverage for breast reconstruction in | connection
with a mastectomy shall
include:
| (1) reconstruction of the breast upon which the | mastectomy has been
performed;
| (2) surgery and reconstruction of the other breast to | produce a
symmetrical appearance; and
| (3) prostheses and treatment for physical | complications at all stages of
mastectomy, including |
| lymphedemas.
| Care shall be determined in consultation with the attending | physician and the
patient.
The offered coverage for prosthetic | devices and
reconstructive surgery shall be subject to the | deductible and coinsurance
conditions applied to the | mastectomy and all other terms and conditions
applicable to | other benefits. When a mastectomy is performed and there is
no | evidence of malignancy, then the offered coverage may be | limited to the
provision of prosthetic devices and | reconstructive surgery to within 2
years after the date of the | mastectomy. As used in this Section,
"mastectomy" means the | removal of all or part of the breast for medically
necessary | reasons, as determined by a licensed physician.
| Written notice of the availability of coverage under this | Section shall be
delivered to the enrollee upon enrollment and | annually thereafter. A
health maintenance organization may not | deny to an enrollee eligibility, or
continued eligibility, to | enroll or
to renew coverage under the terms of the plan solely | for the purpose of
avoiding the requirements of this Section. A | health maintenance organization
may not penalize or
reduce or
| limit the reimbursement of an attending provider or provide | incentives
(monetary or otherwise) to an attending provider to | induce the provider to
provide care to an insured in a manner | inconsistent with this Section.
| (c) Rulemaking authority to implement this amendatory Act | of the 95th General Assembly, if any, is conditioned on the |
| rules being adopted in accordance with all provisions of the | Illinois Administrative Procedure Act and all rules and | procedures of the Joint Committee on Administrative Rules; any | purported rule not so adopted, for whatever reason, is | unauthorized. | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 95-1045, eff. 3-27-09.)
| Section 15. The Illinois Public Aid Code is amended by | changing Section 5-5 as follows:
| (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| Sec. 5-5. Medical services. The Illinois Department, by | rule, shall
determine the quantity and quality of and the rate | of reimbursement for the
medical assistance for which
payment | will be authorized, and the medical services to be provided,
| which may include all or part of the following: (1) inpatient | hospital
services; (2) outpatient hospital services; (3) other | laboratory and
X-ray services; (4) skilled nursing home | services; (5) physicians'
services whether furnished in the | office, the patient's home, a
hospital, a skilled nursing home, | or elsewhere; (6) medical care, or any
other type of remedial | care furnished by licensed practitioners; (7)
home health care | services; (8) private duty nursing service; (9) clinic
| services; (10) dental services, including prevention and | treatment of periodontal disease and dental caries disease for |
| pregnant women, provided by an individual licensed to practice | dentistry or dental surgery; for purposes of this item (10), | "dental services" means diagnostic, preventive, or corrective | procedures provided by or under the supervision of a dentist in | the practice of his or her profession; (11) physical therapy | and related
services; (12) prescribed drugs, dentures, and | prosthetic devices; and
eyeglasses prescribed by a physician | skilled in the diseases of the eye,
or by an optometrist, | whichever the person may select; (13) other
diagnostic, | screening, preventive, and rehabilitative services, including | to ensure that the individual's need for intervention or | treatment of mental disorders or substance use disorders or | co-occurring mental health and substance use disorders is | determined using a uniform screening, assessment, and | evaluation process inclusive of criteria, for children and | adults; for purposes of this item (13), a uniform screening, | assessment, and evaluation process refers to a process that | includes an appropriate evaluation and, as warranted, a | referral; "uniform" does not mean the use of a singular | instrument, tool, or process that all must utilize; (14)
| transportation and such other expenses as may be necessary; | (15) medical
treatment of sexual assault survivors, as defined | in
Section 1a of the Sexual Assault Survivors Emergency | Treatment Act, for
injuries sustained as a result of the sexual | assault, including
examinations and laboratory tests to | discover evidence which may be used in
criminal proceedings |
| arising from the sexual assault; (16) the
diagnosis and | treatment of sickle cell anemia; and (17)
any other medical | care, and any other type of remedial care recognized
under the | laws of this State, but not including abortions, or induced
| miscarriages or premature births, unless, in the opinion of a | physician,
such procedures are necessary for the preservation | of the life of the
woman seeking such treatment, or except an | induced premature birth
intended to produce a live viable child | and such procedure is necessary
for the health of the mother or | her unborn child. The Illinois Department,
by rule, shall | prohibit any physician from providing medical assistance
to | anyone eligible therefor under this Code where such physician | has been
found guilty of performing an abortion procedure in a | wilful and wanton
manner upon a woman who was not pregnant at | the time such abortion
procedure was performed. The term "any | other type of remedial care" shall
include nursing care and | nursing home service for persons who rely on
treatment by | spiritual means alone through prayer for healing.
| Notwithstanding any other provision of this Section, a | comprehensive
tobacco use cessation program that includes | purchasing prescription drugs or
prescription medical devices | approved by the Food and Drug Administration shall
be covered | under the medical assistance
program under this Article for | persons who are otherwise eligible for
assistance under this | Article.
| Notwithstanding any other provision of this Code, the |
| Illinois
Department may not require, as a condition of payment | for any laboratory
test authorized under this Article, that a | physician's handwritten signature
appear on the laboratory | test order form. The Illinois Department may,
however, impose | other appropriate requirements regarding laboratory test
order | documentation.
| Upon receipt of federal approval of an amendment to the | Illinois Title XIX State Plan for this purpose, the Department | shall authorize the Chicago Public Schools (CPS) to procure a | vendor or vendors to manufacture eyeglasses for individuals | enrolled in a school within the CPS system. CPS shall ensure | that its vendor or vendors are enrolled as providers in the | medical assistance program and in any capitated Medicaid | managed care entity (MCE) serving individuals enrolled in a | school within the CPS system. Under any contract procured under | this provision, the vendor or vendors must serve only | individuals enrolled in a school within the CPS system. Claims | for services provided by CPS's vendor or vendors to recipients | of benefits in the medical assistance program under this Code, | the Children's Health Insurance Program, or the Covering ALL | KIDS Health Insurance Program shall be submitted to the | Department or the MCE in which the individual is enrolled for | payment and shall be reimbursed at the Department's or the | MCE's established rates or rate methodologies for eyeglasses. | On and after July 1, 2012, the Department of Healthcare and | Family Services may provide the following services to
persons
|
| eligible for assistance under this Article who are | participating in
education, training or employment programs | operated by the Department of Human
Services as successor to | the Department of Public Aid:
| (1) dental services provided by or under the | supervision of a dentist; and
| (2) eyeglasses prescribed by a physician skilled in the | diseases of the
eye, or by an optometrist, whichever the | person may select.
| Notwithstanding any other provision of this Code and | subject to federal approval, the Department may adopt rules to | allow a dentist who is volunteering his or her service at no | cost to render dental services through an enrolled | not-for-profit health clinic without the dentist personally | enrolling as a participating provider in the medical assistance | program. A not-for-profit health clinic shall include a public | health clinic or Federally Qualified Health Center or other | enrolled provider, as determined by the Department, through | which dental services covered under this Section are performed. | The Department shall establish a process for payment of claims | for reimbursement for covered dental services rendered under | this provision. | The Illinois Department, by rule, may distinguish and | classify the
medical services to be provided only in accordance | with the classes of
persons designated in Section 5-2.
| The Department of Healthcare and Family Services must |
| provide coverage and reimbursement for amino acid-based | elemental formulas, regardless of delivery method, for the | diagnosis and treatment of (i) eosinophilic disorders and (ii) | short bowel syndrome when the prescribing physician has issued | a written order stating that the amino acid-based elemental | formula is medically necessary.
| The Illinois Department shall authorize the provision of, | and shall
authorize payment for, screening by low-dose | mammography for the presence of
occult breast cancer for women | 35 years of age or older who are eligible
for medical | assistance under this Article, as follows: | (A) A baseline
mammogram for women 35 to 39 years of | age.
| (B) An annual mammogram for women 40 years of age or | older. | (C) A mammogram at the age and intervals considered | medically necessary by the woman's health care provider for | women under 40 years of age and having a family history of | breast cancer, prior personal history of breast cancer, | positive genetic testing, or other risk factors. | (D) A comprehensive ultrasound screening of an entire | breast or breasts if a mammogram demonstrates | heterogeneous or dense breast tissue, when medically | necessary as determined by a physician licensed to practice | medicine in all of its branches. | All screenings
shall
include a physical breast exam, |
| instruction on self-examination and
information regarding the | frequency of self-examination and its value as a
preventative | tool. For purposes of this Section, "low-dose mammography" | means
the x-ray examination of the breast using equipment | dedicated specifically
for mammography, including the x-ray | tube, filter, compression device,
and image receptor, with an | average radiation exposure delivery
of less than one rad per | breast for 2 views of an average size breast.
The term also | includes digital mammography and includes breast | tomosynthesis. As used in this Section, the term "breast | tomosynthesis" means a radiologic procedure that involves the | acquisition of projection images over the stationary breast to | produce cross-sectional digital three-dimensional images of | the breast.
| On and after January 1, 2012, providers participating in a | quality improvement program approved by the Department shall be | reimbursed for screening and diagnostic mammography at the same | rate as the Medicare program's rates, including the increased | reimbursement for digital mammography. | The Department shall convene an expert panel including | representatives of hospitals, free-standing mammography | facilities, and doctors, including radiologists, to establish | quality standards. | Subject to federal approval, the Department shall | establish a rate methodology for mammography at federally | qualified health centers and other encounter-rate clinics. |
| These clinics or centers may also collaborate with other | hospital-based mammography facilities. | The Department shall establish a methodology to remind | women who are age-appropriate for screening mammography, but | who have not received a mammogram within the previous 18 | months, of the importance and benefit of screening mammography. | The Department shall establish a performance goal for | primary care providers with respect to their female patients | over age 40 receiving an annual mammogram. This performance | goal shall be used to provide additional reimbursement in the | form of a quality performance bonus to primary care providers | who meet that goal. | The Department shall devise a means of case-managing or | patient navigation for beneficiaries diagnosed with breast | cancer. This program shall initially operate as a pilot program | in areas of the State with the highest incidence of mortality | related to breast cancer. At least one pilot program site shall | be in the metropolitan Chicago area and at least one site shall | be outside the metropolitan Chicago area. An evaluation of the | pilot program shall be carried out measuring health outcomes | and cost of care for those served by the pilot program compared | to similarly situated patients who are not served by the pilot | program. | Any medical or health care provider shall immediately | recommend, to
any pregnant woman who is being provided prenatal | services and is suspected
of drug abuse or is addicted as |
| defined in the Alcoholism and Other Drug Abuse
and Dependency | Act, referral to a local substance abuse treatment provider
| licensed by the Department of Human Services or to a licensed
| hospital which provides substance abuse treatment services. | The Department of Healthcare and Family Services
shall assure | coverage for the cost of treatment of the drug abuse or
| addiction for pregnant recipients in accordance with the | Illinois Medicaid
Program in conjunction with the Department of | Human Services.
| All medical providers providing medical assistance to | pregnant women
under this Code shall receive information from | the Department on the
availability of services under the Drug | Free Families with a Future or any
comparable program providing | case management services for addicted women,
including | information on appropriate referrals for other social services
| that may be needed by addicted women in addition to treatment | for addiction.
| The Illinois Department, in cooperation with the | Departments of Human
Services (as successor to the Department | of Alcoholism and Substance
Abuse) and Public Health, through a | public awareness campaign, may
provide information concerning | treatment for alcoholism and drug abuse and
addiction, prenatal | health care, and other pertinent programs directed at
reducing | the number of drug-affected infants born to recipients of | medical
assistance.
| Neither the Department of Healthcare and Family Services |
| nor the Department of Human
Services shall sanction the | recipient solely on the basis of
her substance abuse.
| The Illinois Department shall establish such regulations | governing
the dispensing of health services under this Article | as it shall deem
appropriate. The Department
should
seek the | advice of formal professional advisory committees appointed by
| the Director of the Illinois Department for the purpose of | providing regular
advice on policy and administrative matters, | information dissemination and
educational activities for | medical and health care providers, and
consistency in | procedures to the Illinois Department.
| The Illinois Department may develop and contract with | Partnerships of
medical providers to arrange medical services | for persons eligible under
Section 5-2 of this Code. | Implementation of this Section may be by
demonstration projects | in certain geographic areas. The Partnership shall
be | represented by a sponsor organization. The Department, by rule, | shall
develop qualifications for sponsors of Partnerships. | Nothing in this
Section shall be construed to require that the | sponsor organization be a
medical organization.
| The sponsor must negotiate formal written contracts with | medical
providers for physician services, inpatient and | outpatient hospital care,
home health services, treatment for | alcoholism and substance abuse, and
other services determined | necessary by the Illinois Department by rule for
delivery by | Partnerships. Physician services must include prenatal and
|
| obstetrical care. The Illinois Department shall reimburse | medical services
delivered by Partnership providers to clients | in target areas according to
provisions of this Article and the | Illinois Health Finance Reform Act,
except that:
| (1) Physicians participating in a Partnership and | providing certain
services, which shall be determined by | the Illinois Department, to persons
in areas covered by the | Partnership may receive an additional surcharge
for such | services.
| (2) The Department may elect to consider and negotiate | financial
incentives to encourage the development of | Partnerships and the efficient
delivery of medical care.
| (3) Persons receiving medical services through | Partnerships may receive
medical and case management | services above the level usually offered
through the | medical assistance program.
| Medical providers shall be required to meet certain | qualifications to
participate in Partnerships to ensure the | delivery of high quality medical
services. These | qualifications shall be determined by rule of the Illinois
| Department and may be higher than qualifications for | participation in the
medical assistance program. Partnership | sponsors may prescribe reasonable
additional qualifications | for participation by medical providers, only with
the prior | written approval of the Illinois Department.
| Nothing in this Section shall limit the free choice of |
| practitioners,
hospitals, and other providers of medical | services by clients.
In order to ensure patient freedom of | choice, the Illinois Department shall
immediately promulgate | all rules and take all other necessary actions so that
provided | services may be accessed from therapeutically certified | optometrists
to the full extent of the Illinois Optometric | Practice Act of 1987 without
discriminating between service | providers.
| The Department shall apply for a waiver from the United | States Health
Care Financing Administration to allow for the | implementation of
Partnerships under this Section.
| The Illinois Department shall require health care | providers to maintain
records that document the medical care | and services provided to recipients
of Medical Assistance under | this Article. Such records must be retained for a period of not | less than 6 years from the date of service or as provided by | applicable State law, whichever period is longer, except that | if an audit is initiated within the required retention period | then the records must be retained until the audit is completed | and every exception is resolved. The Illinois Department shall
| require health care providers to make available, when | authorized by the
patient, in writing, the medical records in a | timely fashion to other
health care providers who are treating | or serving persons eligible for
Medical Assistance under this | Article. All dispensers of medical services
shall be required | to maintain and retain business and professional records
|
| sufficient to fully and accurately document the nature, scope, | details and
receipt of the health care provided to persons | eligible for medical
assistance under this Code, in accordance | with regulations promulgated by
the Illinois Department. The | rules and regulations shall require that proof
of the receipt | of prescription drugs, dentures, prosthetic devices and
| eyeglasses by eligible persons under this Section accompany | each claim
for reimbursement submitted by the dispenser of such | medical services.
No such claims for reimbursement shall be | approved for payment by the Illinois
Department without such | proof of receipt, unless the Illinois Department
shall have put | into effect and shall be operating a system of post-payment
| audit and review which shall, on a sampling basis, be deemed | adequate by
the Illinois Department to assure that such drugs, | dentures, prosthetic
devices and eyeglasses for which payment | is being made are actually being
received by eligible | recipients. Within 90 days after the effective date of
this | amendatory Act of 1984, the Illinois Department shall establish | a
current list of acquisition costs for all prosthetic devices | and any
other items recognized as medical equipment and | supplies reimbursable under
this Article and shall update such | list on a quarterly basis, except that
the acquisition costs of | all prescription drugs shall be updated no
less frequently than | every 30 days as required by Section 5-5.12.
| The rules and regulations of the Illinois Department shall | require
that a written statement including the required opinion |
| of a physician
shall accompany any claim for reimbursement for | abortions, or induced
miscarriages or premature births. This | statement shall indicate what
procedures were used in providing | such medical services.
| Notwithstanding any other law to the contrary, the Illinois | Department shall, within 365 days after July 22, 2013, (the | effective date of Public Act 98-104), establish procedures to | permit skilled care facilities licensed under the Nursing Home | Care Act to submit monthly billing claims for reimbursement | purposes. Following development of these procedures, the | Department shall have an additional 365 days to test the | viability of the new system and to ensure that any necessary | operational or structural changes to its information | technology platforms are implemented. | Notwithstanding any other law to the contrary, the Illinois | Department shall, within 365 days after August 15, 2014 (the | effective date of Public Act 98-963) this amendatory Act of the | 98th General Assembly, establish procedures to permit ID/DD | facilities licensed under the ID/DD Community Care Act to | submit monthly billing claims for reimbursement purposes. | Following development of these procedures, the Department | shall have an additional 365 days to test the viability of the | new system and to ensure that any necessary operational or | structural changes to its information technology platforms are | implemented. | The Illinois Department shall require all dispensers of |
| medical
services, other than an individual practitioner or | group of practitioners,
desiring to participate in the Medical | Assistance program
established under this Article to disclose | all financial, beneficial,
ownership, equity, surety or other | interests in any and all firms,
corporations, partnerships, | associations, business enterprises, joint
ventures, agencies, | institutions or other legal entities providing any
form of | health care services in this State under this Article.
| The Illinois Department may require that all dispensers of | medical
services desiring to participate in the medical | assistance program
established under this Article disclose, | under such terms and conditions as
the Illinois Department may | by rule establish, all inquiries from clients
and attorneys | regarding medical bills paid by the Illinois Department, which
| inquiries could indicate potential existence of claims or liens | for the
Illinois Department.
| Enrollment of a vendor
shall be
subject to a provisional | period and shall be conditional for one year. During the period | of conditional enrollment, the Department may
terminate the | vendor's eligibility to participate in, or may disenroll the | vendor from, the medical assistance
program without cause. | Unless otherwise specified, such termination of eligibility or | disenrollment is not subject to the
Department's hearing | process.
However, a disenrolled vendor may reapply without | penalty.
| The Department has the discretion to limit the conditional |
| enrollment period for vendors based upon category of risk of | the vendor. | Prior to enrollment and during the conditional enrollment | period in the medical assistance program, all vendors shall be | subject to enhanced oversight, screening, and review based on | the risk of fraud, waste, and abuse that is posed by the | category of risk of the vendor. The Illinois Department shall | establish the procedures for oversight, screening, and review, | which may include, but need not be limited to: criminal and | financial background checks; fingerprinting; license, | certification, and authorization verifications; unscheduled or | unannounced site visits; database checks; prepayment audit | reviews; audits; payment caps; payment suspensions; and other | screening as required by federal or State law. | The Department shall define or specify the following: (i) | by provider notice, the "category of risk of the vendor" for | each type of vendor, which shall take into account the level of | screening applicable to a particular category of vendor under | federal law and regulations; (ii) by rule or provider notice, | the maximum length of the conditional enrollment period for | each category of risk of the vendor; and (iii) by rule, the | hearing rights, if any, afforded to a vendor in each category | of risk of the vendor that is terminated or disenrolled during | the conditional enrollment period. | To be eligible for payment consideration, a vendor's | payment claim or bill, either as an initial claim or as a |
| resubmitted claim following prior rejection, must be received | by the Illinois Department, or its fiscal intermediary, no | later than 180 days after the latest date on the claim on which | medical goods or services were provided, with the following | exceptions: | (1) In the case of a provider whose enrollment is in | process by the Illinois Department, the 180-day period | shall not begin until the date on the written notice from | the Illinois Department that the provider enrollment is | complete. | (2) In the case of errors attributable to the Illinois | Department or any of its claims processing intermediaries | which result in an inability to receive, process, or | adjudicate a claim, the 180-day period shall not begin | until the provider has been notified of the error. | (3) In the case of a provider for whom the Illinois | Department initiates the monthly billing process. | (4) In the case of a provider operated by a unit of | local government with a population exceeding 3,000,000 | when local government funds finance federal participation | for claims payments. | For claims for services rendered during a period for which | a recipient received retroactive eligibility, claims must be | filed within 180 days after the Department determines the | applicant is eligible. For claims for which the Illinois | Department is not the primary payer, claims must be submitted |
| to the Illinois Department within 180 days after the final | adjudication by the primary payer. | In the case of long term care facilities, within 5 days of | receipt by the facility of required prescreening information, | data for new admissions shall be entered into the Medical | Electronic Data Interchange (MEDI) or the Recipient | Eligibility Verification (REV) System or successor system, and | within 15 days of receipt by the facility of required | prescreening information, admission documents shall be | submitted through MEDI or REV or shall be submitted directly to | the Department of Human Services using required admission | forms. Effective September
1, 2014, admission documents, | including all prescreening
information, must be submitted | through MEDI or REV. Confirmation numbers assigned to an | accepted transaction shall be retained by a facility to verify | timely submittal. Once an admission transaction has been | completed, all resubmitted claims following prior rejection | are subject to receipt no later than 180 days after the | admission transaction has been completed. | Claims that are not submitted and received in compliance | with the foregoing requirements shall not be eligible for | payment under the medical assistance program, and the State | shall have no liability for payment of those claims. | To the extent consistent with applicable information and | privacy, security, and disclosure laws, State and federal | agencies and departments shall provide the Illinois Department |
| access to confidential and other information and data necessary | to perform eligibility and payment verifications and other | Illinois Department functions. This includes, but is not | limited to: information pertaining to licensure; | certification; earnings; immigration status; citizenship; wage | reporting; unearned and earned income; pension income; | employment; supplemental security income; social security | numbers; National Provider Identifier (NPI) numbers; the | National Practitioner Data Bank (NPDB); program and agency | exclusions; taxpayer identification numbers; tax delinquency; | corporate information; and death records. | The Illinois Department shall enter into agreements with | State agencies and departments, and is authorized to enter into | agreements with federal agencies and departments, under which | such agencies and departments shall share data necessary for | medical assistance program integrity functions and oversight. | The Illinois Department shall develop, in cooperation with | other State departments and agencies, and in compliance with | applicable federal laws and regulations, appropriate and | effective methods to share such data. At a minimum, and to the | extent necessary to provide data sharing, the Illinois | Department shall enter into agreements with State agencies and | departments, and is authorized to enter into agreements with | federal agencies and departments, including but not limited to: | the Secretary of State; the Department of Revenue; the | Department of Public Health; the Department of Human Services; |
| and the Department of Financial and Professional Regulation. | Beginning in fiscal year 2013, the Illinois Department | shall set forth a request for information to identify the | benefits of a pre-payment, post-adjudication, and post-edit | claims system with the goals of streamlining claims processing | and provider reimbursement, reducing the number of pending or | rejected claims, and helping to ensure a more transparent | adjudication process through the utilization of: (i) provider | data verification and provider screening technology; and (ii) | clinical code editing; and (iii) pre-pay, pre- or | post-adjudicated predictive modeling with an integrated case | management system with link analysis. Such a request for | information shall not be considered as a request for proposal | or as an obligation on the part of the Illinois Department to | take any action or acquire any products or services. | The Illinois Department shall establish policies, | procedures,
standards and criteria by rule for the acquisition, | repair and replacement
of orthotic and prosthetic devices and | durable medical equipment. Such
rules shall provide, but not be | limited to, the following services: (1)
immediate repair or | replacement of such devices by recipients; and (2) rental, | lease, purchase or lease-purchase of
durable medical equipment | in a cost-effective manner, taking into
consideration the | recipient's medical prognosis, the extent of the
recipient's | needs, and the requirements and costs for maintaining such
| equipment. Subject to prior approval, such rules shall enable a |
| recipient to temporarily acquire and
use alternative or | substitute devices or equipment pending repairs or
| replacements of any device or equipment previously authorized | for such
recipient by the Department.
| The Department shall execute, relative to the nursing home | prescreening
project, written inter-agency agreements with the | Department of Human
Services and the Department on Aging, to | effect the following: (i) intake
procedures and common | eligibility criteria for those persons who are receiving
| non-institutional services; and (ii) the establishment and | development of
non-institutional services in areas of the State | where they are not currently
available or are undeveloped; and | (iii) notwithstanding any other provision of law, subject to | federal approval, on and after July 1, 2012, an increase in the | determination of need (DON) scores from 29 to 37 for applicants | for institutional and home and community-based long term care; | if and only if federal approval is not granted, the Department | may, in conjunction with other affected agencies, implement | utilization controls or changes in benefit packages to | effectuate a similar savings amount for this population; and | (iv) no later than July 1, 2013, minimum level of care | eligibility criteria for institutional and home and | community-based long term care; and (v) no later than October | 1, 2013, establish procedures to permit long term care | providers access to eligibility scores for individuals with an | admission date who are seeking or receiving services from the |
| long term care provider. In order to select the minimum level | of care eligibility criteria, the Governor shall establish a | workgroup that includes affected agency representatives and | stakeholders representing the institutional and home and | community-based long term care interests. This Section shall | not restrict the Department from implementing lower level of | care eligibility criteria for community-based services in | circumstances where federal approval has been granted.
| The Illinois Department shall develop and operate, in | cooperation
with other State Departments and agencies and in | compliance with
applicable federal laws and regulations, | appropriate and effective
systems of health care evaluation and | programs for monitoring of
utilization of health care services | and facilities, as it affects
persons eligible for medical | assistance under this Code.
| The Illinois Department shall report annually to the | General Assembly,
no later than the second Friday in April of | 1979 and each year
thereafter, in regard to:
| (a) actual statistics and trends in utilization of | medical services by
public aid recipients;
| (b) actual statistics and trends in the provision of | the various medical
services by medical vendors;
| (c) current rate structures and proposed changes in | those rate structures
for the various medical vendors; and
| (d) efforts at utilization review and control by the | Illinois Department.
|
| The period covered by each report shall be the 3 years | ending on the June
30 prior to the report. The report shall | include suggested legislation
for consideration by the General | Assembly. The filing of one copy of the
report with the | Speaker, one copy with the Minority Leader and one copy
with | the Clerk of the House of Representatives, one copy with the | President,
one copy with the Minority Leader and one copy with | the Secretary of the
Senate, one copy with the Legislative | Research Unit, and such additional
copies
with the State | Government Report Distribution Center for the General
Assembly | as is required under paragraph (t) of Section 7 of the State
| Library Act shall be deemed sufficient to comply with this | Section.
| Rulemaking authority to implement Public Act 95-1045, if | any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on | Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | On and after July 1, 2012, the Department shall reduce any | rate of reimbursement for services or other payments or alter | any methodologies authorized by this Code to reduce any rate of | reimbursement for services or other payments in accordance with | Section 5-5e. | Because kidney transplantation can be an appropriate, cost | effective
alternative to renal dialysis when medically |
| necessary and notwithstanding the provisions of Section 1-11 of | this Code, beginning October 1, 2014, the Department shall | cover kidney transplantation for noncitizens with end-stage | renal disease who are not eligible for comprehensive medical | benefits, who meet the residency requirements of Section 5-3 of | this Code, and who would otherwise meet the financial | requirements of the appropriate class of eligible persons under | Section 5-2 of this Code. To qualify for coverage of kidney | transplantation, such person must be receiving emergency renal | dialysis services covered by the Department. Providers under | this Section shall be prior approved and certified by the | Department to perform kidney transplantation and the services | under this Section shall be limited to services associated with | kidney transplantation. | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, | eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14; | revised 10-2-14.)
| Section 99. Effective date. This Act takes effect on July | 1, 2016, if and only if on or before July 1, 2016: | (1) the Secretary of the United States Department of | Health and Human Services, or its successor agency, promulgates | rules or regulations published in the Federal Register or | publishes a comment in the Federal Register: |
| (A) repealing, amending, or reinterpreting 45 CFR | 155.170 to eliminate the State's responsibility to defray | the cost of a state-mandated benefit enacted on or after | January 1, 2012; | (B) requiring qualified health plans, as defined in the | federal Patient Protection and Affordable Care Act, as | amended by the Health Care and Education Reconciliation Act | of 2010 and any subsequent amendatory Acts, rules, or | regulations issued pursuant thereto, to cover breast | tomosynthesis as an essential health benefit; or | (C) including breast tomosynthesis as a standard as | part of the essential health benefits required of benchmark | plans under 45 CFR 156.110; or | (2) the federal Patient Protection and Affordable Care Act | is repealed by an Act of Congress or is invalidated by a | decision of the U.S. Supreme Court. |
Effective Date: 7/1/2016
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