Public Act 099-0407
 
SB0054 EnrolledLRB099 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