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Public Act 100-1009 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 356z.22 as follows: | ||||
(215 ILCS 5/356z.22) | ||||
Sec. 356z.22. Coverage for telehealth services. | ||||
(a) For purposes of this Section: | ||||
"Distant site" means the location at which the health care | ||||
provider rendering the telehealth service is located. | ||||
"Interactive telecommunications system" means an audio and | ||||
video system permitting 2-way, live interactive communication | ||||
between the patient and the distant site health care provider. | ||||
"Telehealth services" means the delivery of covered health | ||||
care services by way of an interactive telecommunications | ||||
system. | ||||
(b) If an individual or group policy of accident or health | ||||
insurance provides coverage for telehealth services, then it | ||||
must comply with the following: | ||||
(1) An individual or group policy of accident or health | ||||
insurance providing telehealth services may not: | ||||
(A) require that in-person contact occur between a | ||||
health care provider and a patient; |
(B) require the health care provider to document a | ||
barrier to an in-person consultation for coverage of | ||
services to be provided through telehealth; | ||
(C) require the use of telehealth when the health | ||
care provider has determined that it is not | ||
appropriate; or | ||
(D) require the use of telehealth when a patient | ||
chooses an in-person consultation. | ||
(2) Deductibles, copayments, or coinsurance applicable | ||
to services provided through telehealth shall not exceed | ||
the deductibles, copayments, or coinsurance required by | ||
the individual or group policy of accident or health | ||
insurance for the same services provided through in-person | ||
consultation. | ||
(b-5) If an individual or group policy of accident or | ||
health insurance provides coverage for telehealth services, it | ||
must provide coverage for licensed dietitian nutritionists and | ||
certified diabetes educators who counsel senior diabetes | ||
patients in the senior diabetes patients' homes to remove the | ||
hurdle of transportation for senior diabetes patients to | ||
receive treatment. | ||
(c) Nothing in this Section shall be deemed as precluding a | ||
health insurer from providing benefits for other services, | ||
including, but not limited to, remote monitoring services, | ||
other monitoring services, or oral communications otherwise | ||
covered under the policy.
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(Source: P.A. 98-1091, eff. 1-1-15 .) | ||
Section 10. The Illinois Public Aid Code is amended by | ||
changing Section 5-5 as follows:
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(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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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,
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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
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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)
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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. 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.
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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.
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Notwithstanding any other provision of this Code, | ||
reproductive health care that is otherwise legal in Illinois | ||
shall be covered under the medical assistance program for | ||
persons who are otherwise eligible for medical 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.
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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
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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:
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(1) dental services provided by or under the | ||
supervision of a dentist; and
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(2) eyeglasses prescribed by a physician skilled in the | ||
diseases of the
eye, or by an optometrist, whichever the | ||
person may select.
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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.
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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.
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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.
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(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 and MRI 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. | ||
(E) A screening MRI 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. If, at any time, the Secretary of the United States | ||
Department of Health and Human Services, or its successor | ||
agency, promulgates rules or regulations to be published in the | ||
Federal Register or publishes a comment in the Federal Register | ||
or issues an opinion, guidance, or other action that would | ||
require the State, pursuant to any provision of the Patient | ||
Protection and Affordable Care Act (Public Law 111-148), | ||
including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | ||
successor provision, to defray the cost of any coverage for | ||
breast tomosynthesis outlined in this paragraph, then the | ||
requirement that an insurer cover breast tomosynthesis is | ||
inoperative other than any such coverage authorized under | ||
Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | ||
the State shall not assume any obligation for the cost of | ||
coverage for breast tomosynthesis set forth in this paragraph.
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On and after January 1, 2016, the Department shall ensure | ||
that all networks of care for adult clients of the Department | ||
include access to at least one breast imaging Center of Imaging | ||
Excellence as certified by the American College of Radiology. | ||
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 for mammography. | ||
On and after January 1, 2017, providers participating in a | ||
breast cancer treatment quality improvement program approved | ||
by the Department shall be reimbursed for breast cancer | ||
treatment at a rate that is no lower than 95% of the Medicare | ||
program's rates for the data elements included in the breast | ||
cancer treatment quality program. | ||
The Department shall convene an expert panel, including | ||
representatives of hospitals, free standing breast cancer | ||
treatment centers, breast cancer quality organizations, and | ||
doctors, including breast surgeons, reconstructive breast | ||
surgeons, oncologists, and primary care providers to establish | ||
quality standards for breast cancer treatment. | ||
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. By January 1, 2016, the | ||
Department shall report to the General Assembly on the status | ||
of the provision set forth in this paragraph. | ||
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 work with experts in breast cancer | ||
outreach and patient navigation to optimize these reminders and | ||
shall establish a methodology for evaluating their | ||
effectiveness and modifying the methodology based on the | ||
evaluation. | ||
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. On or after July 1, | ||
2016, the pilot program shall be expanded to include one site | ||
in western Illinois, one site in southern Illinois, one site in | ||
central Illinois, and 4 sites within metropolitan Chicago. 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. | ||
The Department shall require all networks of care to | ||
develop a means either internally or by contract with experts | ||
in navigation and community outreach to navigate cancer | ||
patients to comprehensive care in a timely fashion. The | ||
Department shall require all networks of care to include access | ||
for patients diagnosed with cancer to at least one academic | ||
commission on cancer-accredited cancer program as an | ||
in-network covered benefit. | ||
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
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licensed by the Department of Human Services or to a licensed
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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
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addiction for pregnant recipients in accordance with the | ||
Illinois Medicaid
Program in conjunction with the Department of | ||
Human Services.
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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
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that may be needed by addicted women in addition to treatment | ||
for addiction.
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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.
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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.
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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.
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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.
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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
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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:
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(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.
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(2) The Department may elect to consider and negotiate | ||
financial
incentives to encourage the development of | ||
Partnerships and the efficient
delivery of medical care.
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(3) Persons receiving medical services through |
Partnerships may receive
medical and case management | ||
services above the level usually offered
through the | ||
medical assistance program.
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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.
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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.
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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.
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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
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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 September 16, 1984 (the | ||
effective date of Public Act 83-1439), 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.
| ||
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, by July 1, 2016, test the viability of the | ||
new system and implement any necessary operational or | ||
structural changes to its information technology platforms in | ||
order to allow for the direct acceptance and payment of nursing | ||
home claims. | ||
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), establish procedures to |
permit ID/DD facilities licensed under the ID/DD Community Care | ||
Act and MC/DD facilities licensed under the MC/DD 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 45 | ||
calendar days of receipt by the facility of required | ||
prescreening information, new admissions with associated | ||
admission documents shall be submitted through the Medical | ||
Electronic Data Interchange (MEDI) or the Recipient | ||
Eligibility Verification (REV) System 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. Notwithstanding any | ||
provision of Section 5-5f to the contrary, the Department may, | ||
by rule, exempt certain replacement wheelchair parts from prior | ||
approval and, for wheelchairs, wheelchair parts, wheelchair | ||
accessories, and related seating and positioning items, | ||
determine the wholesale price by methods other than actual | ||
acquisition costs. | ||
The Department shall require, by rule, all providers of | ||
durable medical equipment to be accredited by an accreditation | ||
organization approved by the federal Centers for Medicare and | ||
Medicaid Services and recognized by the Department in order to | ||
bill the Department for providing durable medical equipment to | ||
recipients. No later than 15 months after the effective date of | ||
the rule adopted pursuant to this paragraph, all providers must | ||
meet the accreditation requirement.
| ||
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. | ||
Notwithstanding any other provision of this Code to the | ||
contrary, on or after July 1, 2015, all FDA approved forms of | ||
medication assisted treatment prescribed for the treatment of | ||
alcohol dependence or treatment of opioid dependence shall be | ||
covered under both fee for service and managed care medical | ||
assistance programs for persons who are otherwise eligible for | ||
medical assistance under this Article and shall not be subject | ||
to any (1) utilization control, other than those established | ||
under the American Society of Addiction Medicine patient | ||
placement criteria,
(2) prior authorization mandate, or (3) | ||
lifetime restriction limit
mandate. | ||
On or after July 1, 2015, opioid antagonists prescribed for | ||
the treatment of an opioid overdose, including the medication | ||
product, administration devices, and any pharmacy fees related | ||
to the dispensing and administration of the opioid antagonist, | ||
shall be covered under the medical assistance program for | ||
persons who are otherwise eligible for medical assistance under | ||
this Article. As used in this Section, "opioid antagonist" |
means a drug that binds to opioid receptors and blocks or | ||
inhibits the effect of opioids acting on those receptors, | ||
including, but not limited to, naloxone hydrochloride or any | ||
other similarly acting drug approved by the U.S. Food and Drug | ||
Administration. | ||
Upon federal approval, the Department shall provide | ||
coverage and reimbursement for all drugs that are approved for | ||
marketing by the federal Food and Drug Administration and that | ||
are recommended by the federal Public Health Service or the | ||
United States Centers for Disease Control and Prevention for | ||
pre-exposure prophylaxis and related pre-exposure prophylaxis | ||
services, including, but not limited to, HIV and sexually | ||
transmitted infection screening, treatment for sexually | ||
transmitted infections, medical monitoring, assorted labs, and | ||
counseling to reduce the likelihood of HIV infection among | ||
individuals who are not infected with HIV but who are at high | ||
risk of HIV infection. | ||
Notwithstanding any other provision of this Code, the | ||
Illinois Department shall authorize licensed dietitian | ||
nutritionists and certified diabetes educators to counsel | ||
senior diabetes patients in the senior diabetes patients' homes | ||
to remove the hurdle of transportation for senior diabetes | ||
patients to receive treatment. | ||
(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | ||
99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | ||
the effective date of P.A. 99-407); 99-433, eff. 8-21-15; |
99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | ||
7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | ||
eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | ||
100-538, eff. 1-1-18; revised 10-26-17.)
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