Illinois 2023-2024 Regular Session

Illinois House Bill HB2373 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2373 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that treatment for a hoarding disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance. LRB103 30342 KTG 56772 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2373 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that treatment for a hoarding disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance. LRB103 30342 KTG 56772 b LRB103 30342 KTG 56772 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2373 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5
4	4	305 ILCS 5/5-5 from Ch. 23, par. 5-5
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that treatment for a hoarding disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance.
6	6	LRB103 30342 KTG 56772 b LRB103 30342 KTG 56772 b
7	7	LRB103 30342 KTG 56772 b
8	8	A BILL FOR
9	9	HB2373LRB103 30342 KTG 56772 b HB2373 LRB103 30342 KTG 56772 b
10	10	HB2373 LRB103 30342 KTG 56772 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5 as follows:
16	16	6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
17	17	7 Sec. 5-5. Medical services. The Illinois Department, by
18	18	8 rule, shall determine the quantity and quality of and the rate
19	19	9 of reimbursement for the medical assistance for which payment
20	20	10 will be authorized, and the medical services to be provided,
21	21	11 which may include all or part of the following: (1) inpatient
22	22	12 hospital services; (2) outpatient hospital services; (3) other
23	23	13 laboratory and X-ray services; (4) skilled nursing home
24	24	14 services; (5) physicians' services whether furnished in the
25	25	15 office, the patient's home, a hospital, a skilled nursing
26	26	16 home, or elsewhere; (6) medical care, or any other type of
27	27	17 remedial care furnished by licensed practitioners; (7) home
28	28	18 health care services; (8) private duty nursing service; (9)
29	29	19 clinic services; (10) dental services, including prevention
30	30	20 and treatment of periodontal disease and dental caries disease
31	31	21 for pregnant individuals, provided by an individual licensed
32	32	22 to practice dentistry or dental surgery; for purposes of this
33	33	23 item (10), "dental services" means diagnostic, preventive, or
34	34
35	35
36	36
37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2373 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5
39	39	305 ILCS 5/5-5 from Ch. 23, par. 5-5
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that treatment for a hoarding disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance.
41	41	LRB103 30342 KTG 56772 b LRB103 30342 KTG 56772 b
42	42	LRB103 30342 KTG 56772 b
43	43	A BILL FOR
44	44
45	45
46	46
47	47
48	48
49	49	305 ILCS 5/5-5 from Ch. 23, par. 5-5
50	50
51	51
52	52
53	53	LRB103 30342 KTG 56772 b
54	54
55	55
56	56
57	57
58	58
59	59
60	60
61	61
62	62
63	63	HB2373 LRB103 30342 KTG 56772 b
64	64
65	65
66	66	HB2373- 2 -LRB103 30342 KTG 56772 b HB2373 - 2 - LRB103 30342 KTG 56772 b
67	67	HB2373 - 2 - LRB103 30342 KTG 56772 b
68	68	1 corrective procedures provided by or under the supervision of
69	69	2 a dentist in the practice of his or her profession; (11)
70	70	3 physical therapy and related services; (12) prescribed drugs,
71	71	4 dentures, and prosthetic devices; and eyeglasses prescribed by
72	72	5 a physician skilled in the diseases of the eye, or by an
73	73	6 optometrist, whichever the person may select; (13) other
74	74	7 diagnostic, screening, preventive, and rehabilitative
75	75	8 services, including to ensure that the individual's need for
76	76	9 intervention or treatment of mental disorders or substance use
77	77	10 disorders or co-occurring mental health and substance use
78	78	11 disorders is determined using a uniform screening, assessment,
79	79	12 and evaluation process inclusive of criteria, for children and
80	80	13 adults; for purposes of this item (13), a uniform screening,
81	81	14 assessment, and evaluation process refers to a process that
82	82	15 includes an appropriate evaluation and, as warranted, a
83	83	16 referral; "uniform" does not mean the use of a singular
84	84	17 instrument, tool, or process that all must utilize; (14)
85	85	18 transportation and such other expenses as may be necessary;
86	86	19 (15) medical treatment of sexual assault survivors, as defined
87	87	20 in Section 1a of the Sexual Assault Survivors Emergency
88	88	21 Treatment Act, for injuries sustained as a result of the
89	89	22 sexual assault, including examinations and laboratory tests to
90	90	23 discover evidence which may be used in criminal proceedings
91	91	24 arising from the sexual assault; (16) the diagnosis and
92	92	25 treatment of sickle cell anemia; (16.5) services performed by
93	93	26 a chiropractic physician licensed under the Medical Practice
94	94
95	95
96	96
97	97
98	98
99	99	HB2373 - 2 - LRB103 30342 KTG 56772 b
100	100
101	101
102	102	HB2373- 3 -LRB103 30342 KTG 56772 b HB2373 - 3 - LRB103 30342 KTG 56772 b
103	103	HB2373 - 3 - LRB103 30342 KTG 56772 b
104	104	1 Act of 1987 and acting within the scope of his or her license,
105	105	2 including, but not limited to, chiropractic manipulative
106	106	3 treatment; and (17) any other medical care, and any other type
107	107	4 of remedial care recognized under the laws of this State. The
108	108	5 term "any other type of remedial care" shall include nursing
109	109	6 care and nursing home service for persons who rely on
110	110	7 treatment by spiritual means alone through prayer for healing.
111	111	8 Notwithstanding any other provision of this Section, a
112	112	9 comprehensive tobacco use cessation program that includes
113	113	10 purchasing prescription drugs or prescription medical devices
114	114	11 approved by the Food and Drug Administration shall be covered
115	115	12 under the medical assistance program under this Article for
116	116	13 persons who are otherwise eligible for assistance under this
117	117	14 Article.
118	118	15 Notwithstanding any other provision of this Code,
119	119	16 reproductive health care that is otherwise legal in Illinois
120	120	17 shall be covered under the medical assistance program for
121	121	18 persons who are otherwise eligible for medical assistance
122	122	19 under this Article.
123	123	20 Notwithstanding any other provision of this Section, all
124	124	21 tobacco cessation medications approved by the United States
125	125	22 Food and Drug Administration and all individual and group
126	126	23 tobacco cessation counseling services and telephone-based
127	127	24 counseling services and tobacco cessation medications provided
128	128	25 through the Illinois Tobacco Quitline shall be covered under
129	129	26 the medical assistance program for persons who are otherwise
130	130
131	131
132	132
133	133
134	134
135	135	HB2373 - 3 - LRB103 30342 KTG 56772 b
136	136
137	137
138	138	HB2373- 4 -LRB103 30342 KTG 56772 b HB2373 - 4 - LRB103 30342 KTG 56772 b
139	139	HB2373 - 4 - LRB103 30342 KTG 56772 b
140	140	1 eligible for assistance under this Article. The Department
141	141	2 shall comply with all federal requirements necessary to obtain
142	142	3 federal financial participation, as specified in 42 CFR
143	143	4 433.15(b)(7), for telephone-based counseling services provided
144	144	5 through the Illinois Tobacco Quitline, including, but not
145	145	6 limited to: (i) entering into a memorandum of understanding or
146	146	7 interagency agreement with the Department of Public Health, as
147	147	8 administrator of the Illinois Tobacco Quitline; and (ii)
148	148	9 developing a cost allocation plan for Medicaid-allowable
149	149	10 Illinois Tobacco Quitline services in accordance with 45 CFR
150	150	11 95.507. The Department shall submit the memorandum of
151	151	12 understanding or interagency agreement, the cost allocation
152	152	13 plan, and all other necessary documentation to the Centers for
153	153	14 Medicare and Medicaid Services for review and approval.
154	154	15 Coverage under this paragraph shall be contingent upon federal
155	155	16 approval.
156	156	17 Notwithstanding any other provision of this Code, the
157	157	18 Illinois Department may not require, as a condition of payment
158	158	19 for any laboratory test authorized under this Article, that a
159	159	20 physician's handwritten signature appear on the laboratory
160	160	21 test order form. The Illinois Department may, however, impose
161	161	22 other appropriate requirements regarding laboratory test order
162	162	23 documentation.
163	163	24 Upon receipt of federal approval of an amendment to the
164	164	25 Illinois Title XIX State Plan for this purpose, the Department
165	165	26 shall authorize the Chicago Public Schools (CPS) to procure a
166	166
167	167
168	168
169	169
170	170
171	171	HB2373 - 4 - LRB103 30342 KTG 56772 b
172	172
173	173
174	174	HB2373- 5 -LRB103 30342 KTG 56772 b HB2373 - 5 - LRB103 30342 KTG 56772 b
175	175	HB2373 - 5 - LRB103 30342 KTG 56772 b
176	176	1 vendor or vendors to manufacture eyeglasses for individuals
177	177	2 enrolled in a school within the CPS system. CPS shall ensure
178	178	3 that its vendor or vendors are enrolled as providers in the
179	179	4 medical assistance program and in any capitated Medicaid
180	180	5 managed care entity (MCE) serving individuals enrolled in a
181	181	6 school within the CPS system. Under any contract procured
182	182	7 under this provision, the vendor or vendors must serve only
183	183	8 individuals enrolled in a school within the CPS system. Claims
184	184	9 for services provided by CPS's vendor or vendors to recipients
185	185	10 of benefits in the medical assistance program under this Code,
186	186	11 the Children's Health Insurance Program, or the Covering ALL
187	187	12 KIDS Health Insurance Program shall be submitted to the
188	188	13 Department or the MCE in which the individual is enrolled for
189	189	14 payment and shall be reimbursed at the Department's or the
190	190	15 MCE's established rates or rate methodologies for eyeglasses.
191	191	16 On and after July 1, 2012, the Department of Healthcare
192	192	17 and Family Services may provide the following services to
193	193	18 persons eligible for assistance under this Article who are
194	194	19 participating in education, training or employment programs
195	195	20 operated by the Department of Human Services as successor to
196	196	21 the Department of Public Aid:
197	197	22 (1) dental services provided by or under the
198	198	23 supervision of a dentist; and
199	199	24 (2) eyeglasses prescribed by a physician skilled in
200	200	25 the diseases of the eye, or by an optometrist, whichever
201	201	26 the person may select.
202	202
203	203
204	204
205	205
206	206
207	207	HB2373 - 5 - LRB103 30342 KTG 56772 b
208	208
209	209
210	210	HB2373- 6 -LRB103 30342 KTG 56772 b HB2373 - 6 - LRB103 30342 KTG 56772 b
211	211	HB2373 - 6 - LRB103 30342 KTG 56772 b
212	212	1 On and after July 1, 2018, the Department of Healthcare
213	213	2 and Family Services shall provide dental services to any adult
214	214	3 who is otherwise eligible for assistance under the medical
215	215	4 assistance program. As used in this paragraph, "dental
216	216	5 services" means diagnostic, preventative, restorative, or
217	217	6 corrective procedures, including procedures and services for
218	218	7 the prevention and treatment of periodontal disease and dental
219	219	8 caries disease, provided by an individual who is licensed to
220	220	9 practice dentistry or dental surgery or who is under the
221	221	10 supervision of a dentist in the practice of his or her
222	222	11 profession.
223	223	12 On and after July 1, 2018, targeted dental services, as
224	224	13 set forth in Exhibit D of the Consent Decree entered by the
225	225	14 United States District Court for the Northern District of
226	226	15 Illinois, Eastern Division, in the matter of Memisovski v.
227	227	16 Maram, Case No. 92 C 1982, that are provided to adults under
228	228	17 the medical assistance program shall be established at no less
229	229	18 than the rates set forth in the "New Rate" column in Exhibit D
230	230	19 of the Consent Decree for targeted dental services that are
231	231	20 provided to persons under the age of 18 under the medical
232	232	21 assistance program.
233	233	22 Notwithstanding any other provision of this Code and
234	234	23 subject to federal approval, the Department may adopt rules to
235	235	24 allow a dentist who is volunteering his or her service at no
236	236	25 cost to render dental services through an enrolled
237	237	26 not-for-profit health clinic without the dentist personally
238	238
239	239
240	240
241	241
242	242
243	243	HB2373 - 6 - LRB103 30342 KTG 56772 b
244	244
245	245
246	246	HB2373- 7 -LRB103 30342 KTG 56772 b HB2373 - 7 - LRB103 30342 KTG 56772 b
247	247	HB2373 - 7 - LRB103 30342 KTG 56772 b
248	248	1 enrolling as a participating provider in the medical
249	249	2 assistance program. A not-for-profit health clinic shall
250	250	3 include a public health clinic or Federally Qualified Health
251	251	4 Center or other enrolled provider, as determined by the
252	252	5 Department, through which dental services covered under this
253	253	6 Section are performed. The Department shall establish a
254	254	7 process for payment of claims for reimbursement for covered
255	255	8 dental services rendered under this provision.
256	256	9 On and after January 1, 2022, the Department of Healthcare
257	257	10 and Family Services shall administer and regulate a
258	258	11 school-based dental program that allows for the out-of-office
259	259	12 delivery of preventative dental services in a school setting
260	260	13 to children under 19 years of age. The Department shall
261	261	14 establish, by rule, guidelines for participation by providers
262	262	15 and set requirements for follow-up referral care based on the
263	263	16 requirements established in the Dental Office Reference Manual
264	264	17 published by the Department that establishes the requirements
265	265	18 for dentists participating in the All Kids Dental School
266	266	19 Program. Every effort shall be made by the Department when
267	267	20 developing the program requirements to consider the different
268	268	21 geographic differences of both urban and rural areas of the
269	269	22 State for initial treatment and necessary follow-up care. No
270	270	23 provider shall be charged a fee by any unit of local government
271	271	24 to participate in the school-based dental program administered
272	272	25 by the Department. Nothing in this paragraph shall be
273	273	26 construed to limit or preempt a home rule unit's or school
274	274
275	275
276	276
277	277
278	278
279	279	HB2373 - 7 - LRB103 30342 KTG 56772 b
280	280
281	281
282	282	HB2373- 8 -LRB103 30342 KTG 56772 b HB2373 - 8 - LRB103 30342 KTG 56772 b
283	283	HB2373 - 8 - LRB103 30342 KTG 56772 b
284	284	1 district's authority to establish, change, or administer a
285	285	2 school-based dental program in addition to, or independent of,
286	286	3 the school-based dental program administered by the
287	287	4 Department.
288	288	5 The Illinois Department, by rule, may distinguish and
289	289	6 classify the medical services to be provided only in
290	290	7 accordance with the classes of persons designated in Section
291	291	8 5-2.
292	292	9 The Department of Healthcare and Family Services must
293	293	10 provide coverage and reimbursement for amino acid-based
294	294	11 elemental formulas, regardless of delivery method, for the
295	295	12 diagnosis and treatment of (i) eosinophilic disorders and (ii)
296	296	13 short bowel syndrome when the prescribing physician has issued
297	297	14 a written order stating that the amino acid-based elemental
298	298	15 formula is medically necessary.
299	299	16 The Illinois Department shall authorize the provision of,
300	300	17 and shall authorize payment for, screening by low-dose
301	301	18 mammography for the presence of occult breast cancer for
302	302	19 individuals 35 years of age or older who are eligible for
303	303	20 medical assistance under this Article, as follows:
304	304	21 (A) A baseline mammogram for individuals 35 to 39
305	305	22 years of age.
306	306	23 (B) An annual mammogram for individuals 40 years of
307	307	24 age or older.
308	308	25 (C) A mammogram at the age and intervals considered
309	309	26 medically necessary by the individual's health care
310	310
311	311
312	312
313	313
314	314
315	315	HB2373 - 8 - LRB103 30342 KTG 56772 b
316	316
317	317
318	318	HB2373- 9 -LRB103 30342 KTG 56772 b HB2373 - 9 - LRB103 30342 KTG 56772 b
319	319	HB2373 - 9 - LRB103 30342 KTG 56772 b
320	320	1 provider for individuals under 40 years of age and having
321	321	2 a family history of breast cancer, prior personal history
322	322	3 of breast cancer, positive genetic testing, or other risk
323	323	4 factors.
324	324	5 (D) A comprehensive ultrasound screening and MRI of an
325	325	6 entire breast or breasts if a mammogram demonstrates
326	326	7 heterogeneous or dense breast tissue or when medically
327	327	8 necessary as determined by a physician licensed to
328	328	9 practice medicine in all of its branches.
329	329	10 (E) A screening MRI when medically necessary, as
330	330	11 determined by a physician licensed to practice medicine in
331	331	12 all of its branches.
332	332	13 (F) A diagnostic mammogram when medically necessary,
333	333	14 as determined by a physician licensed to practice medicine
334	334	15 in all its branches, advanced practice registered nurse,
335	335	16 or physician assistant.
336	336	17 The Department shall not impose a deductible, coinsurance,
337	337	18 copayment, or any other cost-sharing requirement on the
338	338	19 coverage provided under this paragraph; except that this
339	339	20 sentence does not apply to coverage of diagnostic mammograms
340	340	21 to the extent such coverage would disqualify a high-deductible
341	341	22 health plan from eligibility for a health savings account
342	342	23 pursuant to Section 223 of the Internal Revenue Code (26
343	343	24 U.S.C. 223).
344	344	25 All screenings shall include a physical breast exam,
345	345	26 instruction on self-examination and information regarding the
346	346
347	347
348	348
349	349
350	350
351	351	HB2373 - 9 - LRB103 30342 KTG 56772 b
352	352
353	353
354	354	HB2373- 10 -LRB103 30342 KTG 56772 b HB2373 - 10 - LRB103 30342 KTG 56772 b
355	355	HB2373 - 10 - LRB103 30342 KTG 56772 b
356	356	1 frequency of self-examination and its value as a preventative
357	357	2 tool.
358	358	3 For purposes of this Section:
359	359	4 "Diagnostic mammogram" means a mammogram obtained using
360	360	5 diagnostic mammography.
361	361	6 "Diagnostic mammography" means a method of screening that
362	362	7 is designed to evaluate an abnormality in a breast, including
363	363	8 an abnormality seen or suspected on a screening mammogram or a
364	364	9 subjective or objective abnormality otherwise detected in the
365	365	10 breast.
366	366	11 "Low-dose mammography" means the x-ray examination of the
367	367	12 breast using equipment dedicated specifically for mammography,
368	368	13 including the x-ray tube, filter, compression device, and
369	369	14 image receptor, with an average radiation exposure delivery of
370	370	15 less than one rad per breast for 2 views of an average size
371	371	16 breast. The term also includes digital mammography and
372	372	17 includes breast tomosynthesis.
373	373	18 "Breast tomosynthesis" means a radiologic procedure that
374	374	19 involves the acquisition of projection images over the
375	375	20 stationary breast to produce cross-sectional digital
376	376	21 three-dimensional images of the breast.
377	377	22 If, at any time, the Secretary of the United States
378	378	23 Department of Health and Human Services, or its successor
379	379	24 agency, promulgates rules or regulations to be published in
380	380	25 the Federal Register or publishes a comment in the Federal
381	381	26 Register or issues an opinion, guidance, or other action that
382	382
383	383
384	384
385	385
386	386
387	387	HB2373 - 10 - LRB103 30342 KTG 56772 b
388	388
389	389
390	390	HB2373- 11 -LRB103 30342 KTG 56772 b HB2373 - 11 - LRB103 30342 KTG 56772 b
391	391	HB2373 - 11 - LRB103 30342 KTG 56772 b
392	392	1 would require the State, pursuant to any provision of the
393	393	2 Patient Protection and Affordable Care Act (Public Law
394	394	3 111-148), including, but not limited to, 42 U.S.C.
395	395	4 18031(d)(3)(B) or any successor provision, to defray the cost
396	396	5 of any coverage for breast tomosynthesis outlined in this
397	397	6 paragraph, then the requirement that an insurer cover breast
398	398	7 tomosynthesis is inoperative other than any such coverage
399	399	8 authorized under Section 1902 of the Social Security Act, 42
400	400	9 U.S.C. 1396a, and the State shall not assume any obligation
401	401	10 for the cost of coverage for breast tomosynthesis set forth in
402	402	11 this paragraph.
403	403	12 On and after January 1, 2016, the Department shall ensure
404	404	13 that all networks of care for adult clients of the Department
405	405	14 include access to at least one breast imaging Center of
406	406	15 Imaging Excellence as certified by the American College of
407	407	16 Radiology.
408	408	17 On and after January 1, 2012, providers participating in a
409	409	18 quality improvement program approved by the Department shall
410	410	19 be reimbursed for screening and diagnostic mammography at the
411	411	20 same rate as the Medicare program's rates, including the
412	412	21 increased reimbursement for digital mammography and, after
413	413	22 January 1, 2023 (the effective date of Public Act 102-1018)
414	414	23 this amendatory Act of the 102nd General Assembly, breast
415	415	24 tomosynthesis.
416	416	25 The Department shall convene an expert panel including
417	417	26 representatives of hospitals, free-standing mammography
418	418
419	419
420	420
421	421
422	422
423	423	HB2373 - 11 - LRB103 30342 KTG 56772 b
424	424
425	425
426	426	HB2373- 12 -LRB103 30342 KTG 56772 b HB2373 - 12 - LRB103 30342 KTG 56772 b
427	427	HB2373 - 12 - LRB103 30342 KTG 56772 b
428	428	1 facilities, and doctors, including radiologists, to establish
429	429	2 quality standards for mammography.
430	430	3 On and after January 1, 2017, providers participating in a
431	431	4 breast cancer treatment quality improvement program approved
432	432	5 by the Department shall be reimbursed for breast cancer
433	433	6 treatment at a rate that is no lower than 95% of the Medicare
434	434	7 program's rates for the data elements included in the breast
435	435	8 cancer treatment quality program.
436	436	9 The Department shall convene an expert panel, including
437	437	10 representatives of hospitals, free-standing breast cancer
438	438	11 treatment centers, breast cancer quality organizations, and
439	439	12 doctors, including breast surgeons, reconstructive breast
440	440	13 surgeons, oncologists, and primary care providers to establish
441	441	14 quality standards for breast cancer treatment.
442	442	15 Subject to federal approval, the Department shall
443	443	16 establish a rate methodology for mammography at federally
444	444	17 qualified health centers and other encounter-rate clinics.
445	445	18 These clinics or centers may also collaborate with other
446	446	19 hospital-based mammography facilities. By January 1, 2016, the
447	447	20 Department shall report to the General Assembly on the status
448	448	21 of the provision set forth in this paragraph.
449	449	22 The Department shall establish a methodology to remind
450	450	23 individuals who are age-appropriate for screening mammography,
451	451	24 but who have not received a mammogram within the previous 18
452	452	25 months, of the importance and benefit of screening
453	453	26 mammography. The Department shall work with experts in breast
454	454
455	455
456	456
457	457
458	458
459	459	HB2373 - 12 - LRB103 30342 KTG 56772 b
460	460
461	461
462	462	HB2373- 13 -LRB103 30342 KTG 56772 b HB2373 - 13 - LRB103 30342 KTG 56772 b
463	463	HB2373 - 13 - LRB103 30342 KTG 56772 b
464	464	1 cancer outreach and patient navigation to optimize these
465	465	2 reminders and shall establish a methodology for evaluating
466	466	3 their effectiveness and modifying the methodology based on the
467	467	4 evaluation.
468	468	5 The Department shall establish a performance goal for
469	469	6 primary care providers with respect to their female patients
470	470	7 over age 40 receiving an annual mammogram. This performance
471	471	8 goal shall be used to provide additional reimbursement in the
472	472	9 form of a quality performance bonus to primary care providers
473	473	10 who meet that goal.
474	474	11 The Department shall devise a means of case-managing or
475	475	12 patient navigation for beneficiaries diagnosed with breast
476	476	13 cancer. This program shall initially operate as a pilot
477	477	14 program in areas of the State with the highest incidence of
478	478	15 mortality related to breast cancer. At least one pilot program
479	479	16 site shall be in the metropolitan Chicago area and at least one
480	480	17 site shall be outside the metropolitan Chicago area. On or
481	481	18 after July 1, 2016, the pilot program shall be expanded to
482	482	19 include one site in western Illinois, one site in southern
483	483	20 Illinois, one site in central Illinois, and 4 sites within
484	484	21 metropolitan Chicago. An evaluation of the pilot program shall
485	485	22 be carried out measuring health outcomes and cost of care for
486	486	23 those served by the pilot program compared to similarly
487	487	24 situated patients who are not served by the pilot program.
488	488	25 The Department shall require all networks of care to
489	489	26 develop a means either internally or by contract with experts
490	490
491	491
492	492
493	493
494	494
495	495	HB2373 - 13 - LRB103 30342 KTG 56772 b
496	496
497	497
498	498	HB2373- 14 -LRB103 30342 KTG 56772 b HB2373 - 14 - LRB103 30342 KTG 56772 b
499	499	HB2373 - 14 - LRB103 30342 KTG 56772 b
500	500	1 in navigation and community outreach to navigate cancer
501	501	2 patients to comprehensive care in a timely fashion. The
502	502	3 Department shall require all networks of care to include
503	503	4 access for patients diagnosed with cancer to at least one
504	504	5 academic commission on cancer-accredited cancer program as an
505	505	6 in-network covered benefit.
506	506	7 The Department shall provide coverage and reimbursement
507	507	8 for a human papillomavirus (HPV) vaccine that is approved for
508	508	9 marketing by the federal Food and Drug Administration for all
509	509	10 persons between the ages of 9 and 45 and persons of the age of
510	510	11 46 and above who have been diagnosed with cervical dysplasia
511	511	12 with a high risk of recurrence or progression. The Department
512	512	13 shall disallow any preauthorization requirements for the
513	513	14 administration of the human papillomavirus (HPV) vaccine.
514	514	15 On or after July 1, 2022, individuals who are otherwise
515	515	16 eligible for medical assistance under this Article shall
516	516	17 receive coverage for perinatal depression screenings for the
517	517	18 12-month period beginning on the last day of their pregnancy.
518	518	19 Medical assistance coverage under this paragraph shall be
519	519	20 conditioned on the use of a screening instrument approved by
520	520	21 the Department.
521	521	22 Any medical or health care provider shall immediately
522	522	23 recommend, to any pregnant individual who is being provided
523	523	24 prenatal services and is suspected of having a substance use
524	524	25 disorder as defined in the Substance Use Disorder Act,
525	525	26 referral to a local substance use disorder treatment program
526	526
527	527
528	528
529	529
530	530
531	531	HB2373 - 14 - LRB103 30342 KTG 56772 b
532	532
533	533
534	534	HB2373- 15 -LRB103 30342 KTG 56772 b HB2373 - 15 - LRB103 30342 KTG 56772 b
535	535	HB2373 - 15 - LRB103 30342 KTG 56772 b
536	536	1 licensed by the Department of Human Services or to a licensed
537	537	2 hospital which provides substance abuse treatment services.
538	538	3 The Department of Healthcare and Family Services shall assure
539	539	4 coverage for the cost of treatment of the drug abuse or
540	540	5 addiction for pregnant recipients in accordance with the
541	541	6 Illinois Medicaid Program in conjunction with the Department
542	542	7 of Human Services.
543	543	8 All medical providers providing medical assistance to
544	544	9 pregnant individuals under this Code shall receive information
545	545	10 from the Department on the availability of services under any
546	546	11 program providing case management services for addicted
547	547	12 individuals, including information on appropriate referrals
548	548	13 for other social services that may be needed by addicted
549	549	14 individuals in addition to treatment for addiction.
550	550	15 The Illinois Department, in cooperation with the
551	551	16 Departments of Human Services (as successor to the Department
552	552	17 of Alcoholism and Substance Abuse) and Public Health, through
553	553	18 a public awareness campaign, may provide information
554	554	19 concerning treatment for alcoholism and drug abuse and
555	555	20 addiction, prenatal health care, and other pertinent programs
556	556	21 directed at reducing the number of drug-affected infants born
557	557	22 to recipients of medical assistance.
558	558	23 Neither the Department of Healthcare and Family Services
559	559	24 nor the Department of Human Services shall sanction the
560	560	25 recipient solely on the basis of the recipient's substance
561	561	26 abuse.
562	562
563	563
564	564
565	565
566	566
567	567	HB2373 - 15 - LRB103 30342 KTG 56772 b
568	568
569	569
570	570	HB2373- 16 -LRB103 30342 KTG 56772 b HB2373 - 16 - LRB103 30342 KTG 56772 b
571	571	HB2373 - 16 - LRB103 30342 KTG 56772 b
572	572	1 The Illinois Department shall establish such regulations
573	573	2 governing the dispensing of health services under this Article
574	574	3 as it shall deem appropriate. The Department should seek the
575	575	4 advice of formal professional advisory committees appointed by
576	576	5 the Director of the Illinois Department for the purpose of
577	577	6 providing regular advice on policy and administrative matters,
578	578	7 information dissemination and educational activities for
579	579	8 medical and health care providers, and consistency in
580	580	9 procedures to the Illinois Department.
581	581	10 The Illinois Department may develop and contract with
582	582	11 Partnerships of medical providers to arrange medical services
583	583	12 for persons eligible under Section 5-2 of this Code.
584	584	13 Implementation of this Section may be by demonstration
585	585	14 projects in certain geographic areas. The Partnership shall be
586	586	15 represented by a sponsor organization. The Department, by
587	587	16 rule, shall develop qualifications for sponsors of
588	588	17 Partnerships. Nothing in this Section shall be construed to
589	589	18 require that the sponsor organization be a medical
590	590	19 organization.
591	591	20 The sponsor must negotiate formal written contracts with
592	592	21 medical providers for physician services, inpatient and
593	593	22 outpatient hospital care, home health services, treatment for
594	594	23 alcoholism and substance abuse, and other services determined
595	595	24 necessary by the Illinois Department by rule for delivery by
596	596	25 Partnerships. Physician services must include prenatal and
597	597	26 obstetrical care. The Illinois Department shall reimburse
598	598
599	599
600	600
601	601
602	602
603	603	HB2373 - 16 - LRB103 30342 KTG 56772 b
604	604
605	605
606	606	HB2373- 17 -LRB103 30342 KTG 56772 b HB2373 - 17 - LRB103 30342 KTG 56772 b
607	607	HB2373 - 17 - LRB103 30342 KTG 56772 b
608	608	1 medical services delivered by Partnership providers to clients
609	609	2 in target areas according to provisions of this Article and
610	610	3 the Illinois Health Finance Reform Act, except that:
611	611	4 (1) Physicians participating in a Partnership and
612	612	5 providing certain services, which shall be determined by
613	613	6 the Illinois Department, to persons in areas covered by
614	614	7 the Partnership may receive an additional surcharge for
615	615	8 such services.
616	616	9 (2) The Department may elect to consider and negotiate
617	617	10 financial incentives to encourage the development of
618	618	11 Partnerships and the efficient delivery of medical care.
619	619	12 (3) Persons receiving medical services through
620	620	13 Partnerships may receive medical and case management
621	621	14 services above the level usually offered through the
622	622	15 medical assistance program.
623	623	16 Medical providers shall be required to meet certain
624	624	17 qualifications to participate in Partnerships to ensure the
625	625	18 delivery of high quality medical services. These
626	626	19 qualifications shall be determined by rule of the Illinois
627	627	20 Department and may be higher than qualifications for
628	628	21 participation in the medical assistance program. Partnership
629	629	22 sponsors may prescribe reasonable additional qualifications
630	630	23 for participation by medical providers, only with the prior
631	631	24 written approval of the Illinois Department.
632	632	25 Nothing in this Section shall limit the free choice of
633	633	26 practitioners, hospitals, and other providers of medical
634	634
635	635
636	636
637	637
638	638
639	639	HB2373 - 17 - LRB103 30342 KTG 56772 b
640	640
641	641
642	642	HB2373- 18 -LRB103 30342 KTG 56772 b HB2373 - 18 - LRB103 30342 KTG 56772 b
643	643	HB2373 - 18 - LRB103 30342 KTG 56772 b
644	644	1 services by clients. In order to ensure patient freedom of
645	645	2 choice, the Illinois Department shall immediately promulgate
646	646	3 all rules and take all other necessary actions so that
647	647	4 provided services may be accessed from therapeutically
648	648	5 certified optometrists to the full extent of the Illinois
649	649	6 Optometric Practice Act of 1987 without discriminating between
650	650	7 service providers.
651	651	8 The Department shall apply for a waiver from the United
652	652	9 States Health Care Financing Administration to allow for the
653	653	10 implementation of Partnerships under this Section.
654	654	11 The Illinois Department shall require health care
655	655	12 providers to maintain records that document the medical care
656	656	13 and services provided to recipients of Medical Assistance
657	657	14 under this Article. Such records must be retained for a period
658	658	15 of not less than 6 years from the date of service or as
659	659	16 provided by applicable State law, whichever period is longer,
660	660	17 except that if an audit is initiated within the required
661	661	18 retention period then the records must be retained until the
662	662	19 audit is completed and every exception is resolved. The
663	663	20 Illinois Department shall require health care providers to
664	664	21 make available, when authorized by the patient, in writing,
665	665	22 the medical records in a timely fashion to other health care
666	666	23 providers who are treating or serving persons eligible for
667	667	24 Medical Assistance under this Article. All dispensers of
668	668	25 medical services shall be required to maintain and retain
669	669	26 business and professional records sufficient to fully and
670	670
671	671
672	672
673	673
674	674
675	675	HB2373 - 18 - LRB103 30342 KTG 56772 b
676	676
677	677
678	678	HB2373- 19 -LRB103 30342 KTG 56772 b HB2373 - 19 - LRB103 30342 KTG 56772 b
679	679	HB2373 - 19 - LRB103 30342 KTG 56772 b
680	680	1 accurately document the nature, scope, details and receipt of
681	681	2 the health care provided to persons eligible for medical
682	682	3 assistance under this Code, in accordance with regulations
683	683	4 promulgated by the Illinois Department. The rules and
684	684	5 regulations shall require that proof of the receipt of
685	685	6 prescription drugs, dentures, prosthetic devices and
686	686	7 eyeglasses by eligible persons under this Section accompany
687	687	8 each claim for reimbursement submitted by the dispenser of
688	688	9 such medical services. No such claims for reimbursement shall
689	689	10 be approved for payment by the Illinois Department without
690	690	11 such proof of receipt, unless the Illinois Department shall
691	691	12 have put into effect and shall be operating a system of
692	692	13 post-payment audit and review which shall, on a sampling
693	693	14 basis, be deemed adequate by the Illinois Department to assure
694	694	15 that such drugs, dentures, prosthetic devices and eyeglasses
695	695	16 for which payment is being made are actually being received by
696	696	17 eligible recipients. Within 90 days after September 16, 1984
697	697	18 (the effective date of Public Act 83-1439), the Illinois
698	698	19 Department shall establish a current list of acquisition costs
699	699	20 for all prosthetic devices and any other items recognized as
700	700	21 medical equipment and supplies reimbursable under this Article
701	701	22 and shall update such list on a quarterly basis, except that
702	702	23 the acquisition costs of all prescription drugs shall be
703	703	24 updated no less frequently than every 30 days as required by
704	704	25 Section 5-5.12.
705	705	26 Notwithstanding any other law to the contrary, the
706	706
707	707
708	708
709	709
710	710
711	711	HB2373 - 19 - LRB103 30342 KTG 56772 b
712	712
713	713
714	714	HB2373- 20 -LRB103 30342 KTG 56772 b HB2373 - 20 - LRB103 30342 KTG 56772 b
715	715	HB2373 - 20 - LRB103 30342 KTG 56772 b
716	716	1 Illinois Department shall, within 365 days after July 22, 2013
717	717	2 (the effective date of Public Act 98-104), establish
718	718	3 procedures to permit skilled care facilities licensed under
719	719	4 the Nursing Home Care Act to submit monthly billing claims for
720	720	5 reimbursement purposes. Following development of these
721	721	6 procedures, the Department shall, by July 1, 2016, test the
722	722	7 viability of the new system and implement any necessary
723	723	8 operational or structural changes to its information
724	724	9 technology platforms in order to allow for the direct
725	725	10 acceptance and payment of nursing home claims.
726	726	11 Notwithstanding any other law to the contrary, the
727	727	12 Illinois Department shall, within 365 days after August 15,
728	728	13 2014 (the effective date of Public Act 98-963), establish
729	729	14 procedures to permit ID/DD facilities licensed under the ID/DD
730	730	15 Community Care Act and MC/DD facilities licensed under the
731	731	16 MC/DD Act to submit monthly billing claims for reimbursement
732	732	17 purposes. Following development of these procedures, the
733	733	18 Department shall have an additional 365 days to test the
734	734	19 viability of the new system and to ensure that any necessary
735	735	20 operational or structural changes to its information
736	736	21 technology platforms are implemented.
737	737	22 The Illinois Department shall require all dispensers of
738	738	23 medical services, other than an individual practitioner or
739	739	24 group of practitioners, desiring to participate in the Medical
740	740	25 Assistance program established under this Article to disclose
741	741	26 all financial, beneficial, ownership, equity, surety or other
742	742
743	743
744	744
745	745
746	746
747	747	HB2373 - 20 - LRB103 30342 KTG 56772 b
748	748
749	749
750	750	HB2373- 21 -LRB103 30342 KTG 56772 b HB2373 - 21 - LRB103 30342 KTG 56772 b
751	751	HB2373 - 21 - LRB103 30342 KTG 56772 b
752	752	1 interests in any and all firms, corporations, partnerships,
753	753	2 associations, business enterprises, joint ventures, agencies,
754	754	3 institutions or other legal entities providing any form of
755	755	4 health care services in this State under this Article.
756	756	5 The Illinois Department may require that all dispensers of
757	757	6 medical services desiring to participate in the medical
758	758	7 assistance program established under this Article disclose,
759	759	8 under such terms and conditions as the Illinois Department may
760	760	9 by rule establish, all inquiries from clients and attorneys
761	761	10 regarding medical bills paid by the Illinois Department, which
762	762	11 inquiries could indicate potential existence of claims or
763	763	12 liens for the Illinois Department.
764	764	13 Enrollment of a vendor shall be subject to a provisional
765	765	14 period and shall be conditional for one year. During the
766	766	15 period of conditional enrollment, the Department may terminate
767	767	16 the vendor's eligibility to participate in, or may disenroll
768	768	17 the vendor from, the medical assistance program without cause.
769	769	18 Unless otherwise specified, such termination of eligibility or
770	770	19 disenrollment is not subject to the Department's hearing
771	771	20 process. However, a disenrolled vendor may reapply without
772	772	21 penalty.
773	773	22 The Department has the discretion to limit the conditional
774	774	23 enrollment period for vendors based upon the category of risk
775	775	24 of the vendor.
776	776	25 Prior to enrollment and during the conditional enrollment
777	777	26 period in the medical assistance program, all vendors shall be
778	778
779	779
780	780
781	781
782	782
783	783	HB2373 - 21 - LRB103 30342 KTG 56772 b
784	784
785	785
786	786	HB2373- 22 -LRB103 30342 KTG 56772 b HB2373 - 22 - LRB103 30342 KTG 56772 b
787	787	HB2373 - 22 - LRB103 30342 KTG 56772 b
788	788	1 subject to enhanced oversight, screening, and review based on
789	789	2 the risk of fraud, waste, and abuse that is posed by the
790	790	3 category of risk of the vendor. The Illinois Department shall
791	791	4 establish the procedures for oversight, screening, and review,
792	792	5 which may include, but need not be limited to: criminal and
793	793	6 financial background checks; fingerprinting; license,
794	794	7 certification, and authorization verifications; unscheduled or
795	795	8 unannounced site visits; database checks; prepayment audit
796	796	9 reviews; audits; payment caps; payment suspensions; and other
797	797	10 screening as required by federal or State law.
798	798	11 The Department shall define or specify the following: (i)
799	799	12 by provider notice, the "category of risk of the vendor" for
800	800	13 each type of vendor, which shall take into account the level of
801	801	14 screening applicable to a particular category of vendor under
802	802	15 federal law and regulations; (ii) by rule or provider notice,
803	803	16 the maximum length of the conditional enrollment period for
804	804	17 each category of risk of the vendor; and (iii) by rule, the
805	805	18 hearing rights, if any, afforded to a vendor in each category
806	806	19 of risk of the vendor that is terminated or disenrolled during
807	807	20 the conditional enrollment period.
808	808	21 To be eligible for payment consideration, a vendor's
809	809	22 payment claim or bill, either as an initial claim or as a
810	810	23 resubmitted claim following prior rejection, must be received
811	811	24 by the Illinois Department, or its fiscal intermediary, no
812	812	25 later than 180 days after the latest date on the claim on which
813	813	26 medical goods or services were provided, with the following
814	814
815	815
816	816
817	817
818	818
819	819	HB2373 - 22 - LRB103 30342 KTG 56772 b
820	820
821	821
822	822	HB2373- 23 -LRB103 30342 KTG 56772 b HB2373 - 23 - LRB103 30342 KTG 56772 b
823	823	HB2373 - 23 - LRB103 30342 KTG 56772 b
824	824	1 exceptions:
825	825	2 (1) In the case of a provider whose enrollment is in
826	826	3 process by the Illinois Department, the 180-day period
827	827	4 shall not begin until the date on the written notice from
828	828	5 the Illinois Department that the provider enrollment is
829	829	6 complete.
830	830	7 (2) In the case of errors attributable to the Illinois
831	831	8 Department or any of its claims processing intermediaries
832	832	9 which result in an inability to receive, process, or
833	833	10 adjudicate a claim, the 180-day period shall not begin
834	834	11 until the provider has been notified of the error.
835	835	12 (3) In the case of a provider for whom the Illinois
836	836	13 Department initiates the monthly billing process.
837	837	14 (4) In the case of a provider operated by a unit of
838	838	15 local government with a population exceeding 3,000,000
839	839	16 when local government funds finance federal participation
840	840	17 for claims payments.
841	841	18 For claims for services rendered during a period for which
842	842	19 a recipient received retroactive eligibility, claims must be
843	843	20 filed within 180 days after the Department determines the
844	844	21 applicant is eligible. For claims for which the Illinois
845	845	22 Department is not the primary payer, claims must be submitted
846	846	23 to the Illinois Department within 180 days after the final
847	847	24 adjudication by the primary payer.
848	848	25 In the case of long term care facilities, within 120
849	849	26 calendar days of receipt by the facility of required
850	850
851	851
852	852
853	853
854	854
855	855	HB2373 - 23 - LRB103 30342 KTG 56772 b
856	856
857	857
858	858	HB2373- 24 -LRB103 30342 KTG 56772 b HB2373 - 24 - LRB103 30342 KTG 56772 b
859	859	HB2373 - 24 - LRB103 30342 KTG 56772 b
860	860	1 prescreening information, new admissions with associated
861	861	2 admission documents shall be submitted through the Medical
862	862	3 Electronic Data Interchange (MEDI) or the Recipient
863	863	4 Eligibility Verification (REV) System or shall be submitted
864	864	5 directly to the Department of Human Services using required
865	865	6 admission forms. Effective September 1, 2014, admission
866	866	7 documents, including all prescreening information, must be
867	867	8 submitted through MEDI or REV. Confirmation numbers assigned
868	868	9 to an accepted transaction shall be retained by a facility to
869	869	10 verify timely submittal. Once an admission transaction has
870	870	11 been completed, all resubmitted claims following prior
871	871	12 rejection are subject to receipt no later than 180 days after
872	872	13 the admission transaction has been completed.
873	873	14 Claims that are not submitted and received in compliance
874	874	15 with the foregoing requirements shall not be eligible for
875	875	16 payment under the medical assistance program, and the State
876	876	17 shall have no liability for payment of those claims.
877	877	18 To the extent consistent with applicable information and
878	878	19 privacy, security, and disclosure laws, State and federal
879	879	20 agencies and departments shall provide the Illinois Department
880	880	21 access to confidential and other information and data
881	881	22 necessary to perform eligibility and payment verifications and
882	882	23 other Illinois Department functions. This includes, but is not
883	883	24 limited to: information pertaining to licensure;
884	884	25 certification; earnings; immigration status; citizenship; wage
885	885	26 reporting; unearned and earned income; pension income;
886	886
887	887
888	888
889	889
890	890
891	891	HB2373 - 24 - LRB103 30342 KTG 56772 b
892	892
893	893
894	894	HB2373- 25 -LRB103 30342 KTG 56772 b HB2373 - 25 - LRB103 30342 KTG 56772 b
895	895	HB2373 - 25 - LRB103 30342 KTG 56772 b
896	896	1 employment; supplemental security income; social security
897	897	2 numbers; National Provider Identifier (NPI) numbers; the
898	898	3 National Practitioner Data Bank (NPDB); program and agency
899	899	4 exclusions; taxpayer identification numbers; tax delinquency;
900	900	5 corporate information; and death records.
901	901	6 The Illinois Department shall enter into agreements with
902	902	7 State agencies and departments, and is authorized to enter
903	903	8 into agreements with federal agencies and departments, under
904	904	9 which such agencies and departments shall share data necessary
905	905	10 for medical assistance program integrity functions and
906	906	11 oversight. The Illinois Department shall develop, in
907	907	12 cooperation with other State departments and agencies, and in
908	908	13 compliance with applicable federal laws and regulations,
909	909	14 appropriate and effective methods to share such data. At a
910	910	15 minimum, and to the extent necessary to provide data sharing,
911	911	16 the Illinois Department shall enter into agreements with State
912	912	17 agencies and departments, and is authorized to enter into
913	913	18 agreements with federal agencies and departments, including,
914	914	19 but not limited to: the Secretary of State; the Department of
915	915	20 Revenue; the Department of Public Health; the Department of
916	916	21 Human Services; and the Department of Financial and
917	917	22 Professional Regulation.
918	918	23 Beginning in fiscal year 2013, the Illinois Department
919	919	24 shall set forth a request for information to identify the
920	920	25 benefits of a pre-payment, post-adjudication, and post-edit
921	921	26 claims system with the goals of streamlining claims processing
922	922
923	923
924	924
925	925
926	926
927	927	HB2373 - 25 - LRB103 30342 KTG 56772 b
928	928
929	929
930	930	HB2373- 26 -LRB103 30342 KTG 56772 b HB2373 - 26 - LRB103 30342 KTG 56772 b
931	931	HB2373 - 26 - LRB103 30342 KTG 56772 b
932	932	1 and provider reimbursement, reducing the number of pending or
933	933	2 rejected claims, and helping to ensure a more transparent
934	934	3 adjudication process through the utilization of: (i) provider
935	935	4 data verification and provider screening technology; and (ii)
936	936	5 clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
937	937	6 or post-adjudicated predictive modeling with an integrated
938	938	7 case management system with link analysis. Such a request for
939	939	8 information shall not be considered as a request for proposal
940	940	9 or as an obligation on the part of the Illinois Department to
941	941	10 take any action or acquire any products or services.
942	942	11 The Illinois Department shall establish policies,
943	943	12 procedures, standards and criteria by rule for the
944	944	13 acquisition, repair and replacement of orthotic and prosthetic
945	945	14 devices and durable medical equipment. Such rules shall
946	946	15 provide, but not be limited to, the following services: (1)
947	947	16 immediate repair or replacement of such devices by recipients;
948	948	17 and (2) rental, lease, purchase or lease-purchase of durable
949	949	18 medical equipment in a cost-effective manner, taking into
950	950	19 consideration the recipient's medical prognosis, the extent of
951	951	20 the recipient's needs, and the requirements and costs for
952	952	21 maintaining such equipment. Subject to prior approval, such
953	953	22 rules shall enable a recipient to temporarily acquire and use
954	954	23 alternative or substitute devices or equipment pending repairs
955	955	24 or replacements of any device or equipment previously
956	956	25 authorized for such recipient by the Department.
957	957	26 Notwithstanding any provision of Section 5-5f to the contrary,
958	958
959	959
960	960
961	961
962	962
963	963	HB2373 - 26 - LRB103 30342 KTG 56772 b
964	964
965	965
966	966	HB2373- 27 -LRB103 30342 KTG 56772 b HB2373 - 27 - LRB103 30342 KTG 56772 b
967	967	HB2373 - 27 - LRB103 30342 KTG 56772 b
968	968	1 the Department may, by rule, exempt certain replacement
969	969	2 wheelchair parts from prior approval and, for wheelchairs,
970	970	3 wheelchair parts, wheelchair accessories, and related seating
971	971	4 and positioning items, determine the wholesale price by
972	972	5 methods other than actual acquisition costs.
973	973	6 The Department shall require, by rule, all providers of
974	974	7 durable medical equipment to be accredited by an accreditation
975	975	8 organization approved by the federal Centers for Medicare and
976	976	9 Medicaid Services and recognized by the Department in order to
977	977	10 bill the Department for providing durable medical equipment to
978	978	11 recipients. No later than 15 months after the effective date
979	979	12 of the rule adopted pursuant to this paragraph, all providers
980	980	13 must meet the accreditation requirement.
981	981	14 In order to promote environmental responsibility, meet the
982	982	15 needs of recipients and enrollees, and achieve significant
983	983	16 cost savings, the Department, or a managed care organization
984	984	17 under contract with the Department, may provide recipients or
985	985	18 managed care enrollees who have a prescription or Certificate
986	986	19 of Medical Necessity access to refurbished durable medical
987	987	20 equipment under this Section (excluding prosthetic and
988	988	21 orthotic devices as defined in the Orthotics, Prosthetics, and
989	989	22 Pedorthics Practice Act and complex rehabilitation technology
990	990	23 products and associated services) through the State's
991	991	24 assistive technology program's reutilization program, using
992	992	25 staff with the Assistive Technology Professional (ATP)
993	993	26 Certification if the refurbished durable medical equipment:
994	994
995	995
996	996
997	997
998	998
999	999	HB2373 - 27 - LRB103 30342 KTG 56772 b
1000	1000
1001	1001
1002	1002	HB2373- 28 -LRB103 30342 KTG 56772 b HB2373 - 28 - LRB103 30342 KTG 56772 b
1003	1003	HB2373 - 28 - LRB103 30342 KTG 56772 b
1004	1004	1 (i) is available; (ii) is less expensive, including shipping
1005	1005	2 costs, than new durable medical equipment of the same type;
1006	1006	3 (iii) is able to withstand at least 3 years of use; (iv) is
1007	1007	4 cleaned, disinfected, sterilized, and safe in accordance with
1008	1008	5 federal Food and Drug Administration regulations and guidance
1009	1009	6 governing the reprocessing of medical devices in health care
1010	1010	7 settings; and (v) equally meets the needs of the recipient or
1011	1011	8 enrollee. The reutilization program shall confirm that the
1012	1012	9 recipient or enrollee is not already in receipt of the same or
1013	1013	10 similar equipment from another service provider, and that the
1014	1014	11 refurbished durable medical equipment equally meets the needs
1015	1015	12 of the recipient or enrollee. Nothing in this paragraph shall
1016	1016	13 be construed to limit recipient or enrollee choice to obtain
1017	1017	14 new durable medical equipment or place any additional prior
1018	1018	15 authorization conditions on enrollees of managed care
1019	1019	16 organizations.
1020	1020	17 The Department shall execute, relative to the nursing home
1021	1021	18 prescreening project, written inter-agency agreements with the
1022	1022	19 Department of Human Services and the Department on Aging, to
1023	1023	20 effect the following: (i) intake procedures and common
1024	1024	21 eligibility criteria for those persons who are receiving
1025	1025	22 non-institutional services; and (ii) the establishment and
1026	1026	23 development of non-institutional services in areas of the
1027	1027	24 State where they are not currently available or are
1028	1028	25 undeveloped; and (iii) notwithstanding any other provision of
1029	1029	26 law, subject to federal approval, on and after July 1, 2012, an
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB2373 - 28 - LRB103 30342 KTG 56772 b
1036	1036
1037	1037
1038	1038	HB2373- 29 -LRB103 30342 KTG 56772 b HB2373 - 29 - LRB103 30342 KTG 56772 b
1039	1039	HB2373 - 29 - LRB103 30342 KTG 56772 b
1040	1040	1 increase in the determination of need (DON) scores from 29 to
1041	1041	2 37 for applicants for institutional and home and
1042	1042	3 community-based long term care; if and only if federal
1043	1043	4 approval is not granted, the Department may, in conjunction
1044	1044	5 with other affected agencies, implement utilization controls
1045	1045	6 or changes in benefit packages to effectuate a similar savings
1046	1046	7 amount for this population; and (iv) no later than July 1,
1047	1047	8 2013, minimum level of care eligibility criteria for
1048	1048	9 institutional and home and community-based long term care; and
1049	1049	10 (v) no later than October 1, 2013, establish procedures to
1050	1050	11 permit long term care providers access to eligibility scores
1051	1051	12 for individuals with an admission date who are seeking or
1052	1052	13 receiving services from the long term care provider. In order
1053	1053	14 to select the minimum level of care eligibility criteria, the
1054	1054	15 Governor shall establish a workgroup that includes affected
1055	1055	16 agency representatives and stakeholders representing the
1056	1056	17 institutional and home and community-based long term care
1057	1057	18 interests. This Section shall not restrict the Department from
1058	1058	19 implementing lower level of care eligibility criteria for
1059	1059	20 community-based services in circumstances where federal
1060	1060	21 approval has been granted.
1061	1061	22 The Illinois Department shall develop and operate, in
1062	1062	23 cooperation with other State Departments and agencies and in
1063	1063	24 compliance with applicable federal laws and regulations,
1064	1064	25 appropriate and effective systems of health care evaluation
1065	1065	26 and programs for monitoring of utilization of health care
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB2373 - 29 - LRB103 30342 KTG 56772 b
1072	1072
1073	1073
1074	1074	HB2373- 30 -LRB103 30342 KTG 56772 b HB2373 - 30 - LRB103 30342 KTG 56772 b
1075	1075	HB2373 - 30 - LRB103 30342 KTG 56772 b
1076	1076	1 services and facilities, as it affects persons eligible for
1077	1077	2 medical assistance under this Code.
1078	1078	3 The Illinois Department shall report annually to the
1079	1079	4 General Assembly, no later than the second Friday in April of
1080	1080	5 1979 and each year thereafter, in regard to:
1081	1081	6 (a) actual statistics and trends in utilization of
1082	1082	7 medical services by public aid recipients;
1083	1083	8 (b) actual statistics and trends in the provision of
1084	1084	9 the various medical services by medical vendors;
1085	1085	10 (c) current rate structures and proposed changes in
1086	1086	11 those rate structures for the various medical vendors; and
1087	1087	12 (d) efforts at utilization review and control by the
1088	1088	13 Illinois Department.
1089	1089	14 The period covered by each report shall be the 3 years
1090	1090	15 ending on the June 30 prior to the report. The report shall
1091	1091	16 include suggested legislation for consideration by the General
1092	1092	17 Assembly. The requirement for reporting to the General
1093	1093	18 Assembly shall be satisfied by filing copies of the report as
1094	1094	19 required by Section 3.1 of the General Assembly Organization
1095	1095	20 Act, and filing such additional copies with the State
1096	1096	21 Government Report Distribution Center for the General Assembly
1097	1097	22 as is required under paragraph (t) of Section 7 of the State
1098	1098	23 Library Act.
1099	1099	24 Rulemaking authority to implement Public Act 95-1045, if
1100	1100	25 any, is conditioned on the rules being adopted in accordance
1101	1101	26 with all provisions of the Illinois Administrative Procedure
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB2373 - 30 - LRB103 30342 KTG 56772 b
1108	1108
1109	1109
1110	1110	HB2373- 31 -LRB103 30342 KTG 56772 b HB2373 - 31 - LRB103 30342 KTG 56772 b
1111	1111	HB2373 - 31 - LRB103 30342 KTG 56772 b
1112	1112	1 Act and all rules and procedures of the Joint Committee on
1113	1113	2 Administrative Rules; any purported rule not so adopted, for
1114	1114	3 whatever reason, is unauthorized.
1115	1115	4 On and after July 1, 2012, the Department shall reduce any
1116	1116	5 rate of reimbursement for services or other payments or alter
1117	1117	6 any methodologies authorized by this Code to reduce any rate
1118	1118	7 of reimbursement for services or other payments in accordance
1119	1119	8 with Section 5-5e.
1120	1120	9 Because kidney transplantation can be an appropriate,
1121	1121	10 cost-effective alternative to renal dialysis when medically
1122	1122	11 necessary and notwithstanding the provisions of Section 1-11
1123	1123	12 of this Code, beginning October 1, 2014, the Department shall
1124	1124	13 cover kidney transplantation for noncitizens with end-stage
1125	1125	14 renal disease who are not eligible for comprehensive medical
1126	1126	15 benefits, who meet the residency requirements of Section 5-3
1127	1127	16 of this Code, and who would otherwise meet the financial
1128	1128	17 requirements of the appropriate class of eligible persons
1129	1129	18 under Section 5-2 of this Code. To qualify for coverage of
1130	1130	19 kidney transplantation, such person must be receiving
1131	1131	20 emergency renal dialysis services covered by the Department.
1132	1132	21 Providers under this Section shall be prior approved and
1133	1133	22 certified by the Department to perform kidney transplantation
1134	1134	23 and the services under this Section shall be limited to
1135	1135	24 services associated with kidney transplantation.
1136	1136	25 Notwithstanding any other provision of this Code to the
1137	1137	26 contrary, on or after July 1, 2015, all FDA approved forms of
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB2373 - 31 - LRB103 30342 KTG 56772 b
1144	1144
1145	1145
1146	1146	HB2373- 32 -LRB103 30342 KTG 56772 b HB2373 - 32 - LRB103 30342 KTG 56772 b
1147	1147	HB2373 - 32 - LRB103 30342 KTG 56772 b
1148	1148	1 medication assisted treatment prescribed for the treatment of
1149	1149	2 alcohol dependence or treatment of opioid dependence shall be
1150	1150	3 covered under both fee for service and managed care medical
1151	1151	4 assistance programs for persons who are otherwise eligible for
1152	1152	5 medical assistance under this Article and shall not be subject
1153	1153	6 to any (1) utilization control, other than those established
1154	1154	7 under the American Society of Addiction Medicine patient
1155	1155	8 placement criteria, (2) prior authorization mandate, or (3)
1156	1156	9 lifetime restriction limit mandate.
1157	1157	10 On or after July 1, 2015, opioid antagonists prescribed
1158	1158	11 for the treatment of an opioid overdose, including the
1159	1159	12 medication product, administration devices, and any pharmacy
1160	1160	13 fees or hospital fees related to the dispensing, distribution,
1161	1161	14 and administration of the opioid antagonist, shall be covered
1162	1162	15 under the medical assistance program for persons who are
1163	1163	16 otherwise eligible for medical assistance under this Article.
1164	1164	17 As used in this Section, "opioid antagonist" means a drug that
1165	1165	18 binds to opioid receptors and blocks or inhibits the effect of
1166	1166	19 opioids acting on those receptors, including, but not limited
1167	1167	20 to, naloxone hydrochloride or any other similarly acting drug
1168	1168	21 approved by the U.S. Food and Drug Administration. The
1169	1169	22 Department shall not impose a copayment on the coverage
1170	1170	23 provided for naloxone hydrochloride under the medical
1171	1171	24 assistance program.
1172	1172	25 Upon federal approval, the Department shall provide
1173	1173	26 coverage and reimbursement for all drugs that are approved for
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB2373 - 32 - LRB103 30342 KTG 56772 b
1180	1180
1181	1181
1182	1182	HB2373- 33 -LRB103 30342 KTG 56772 b HB2373 - 33 - LRB103 30342 KTG 56772 b
1183	1183	HB2373 - 33 - LRB103 30342 KTG 56772 b
1184	1184	1 marketing by the federal Food and Drug Administration and that
1185	1185	2 are recommended by the federal Public Health Service or the
1186	1186	3 United States Centers for Disease Control and Prevention for
1187	1187	4 pre-exposure prophylaxis and related pre-exposure prophylaxis
1188	1188	5 services, including, but not limited to, HIV and sexually
1189	1189	6 transmitted infection screening, treatment for sexually
1190	1190	7 transmitted infections, medical monitoring, assorted labs, and
1191	1191	8 counseling to reduce the likelihood of HIV infection among
1192	1192	9 individuals who are not infected with HIV but who are at high
1193	1193	10 risk of HIV infection.
1194	1194	11 A federally qualified health center, as defined in Section
1195	1195	12 1905(l)(2)(B) of the federal Social Security Act, shall be
1196	1196	13 reimbursed by the Department in accordance with the federally
1197	1197	14 qualified health center's encounter rate for services provided
1198	1198	15 to medical assistance recipients that are performed by a
1199	1199	16 dental hygienist, as defined under the Illinois Dental
1200	1200	17 Practice Act, working under the general supervision of a
1201	1201	18 dentist and employed by a federally qualified health center.
1202	1202	19 Within 90 days after October 8, 2021 (the effective date
1203	1203	20 of Public Act 102-665), the Department shall seek federal
1204	1204	21 approval of a State Plan amendment to expand coverage for
1205	1205	22 family planning services that includes presumptive eligibility
1206	1206	23 to individuals whose income is at or below 208% of the federal
1207	1207	24 poverty level. Coverage under this Section shall be effective
1208	1208	25 beginning no later than December 1, 2022.
1209	1209	26 Subject to approval by the federal Centers for Medicare
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB2373 - 33 - LRB103 30342 KTG 56772 b
1216	1216
1217	1217
1218	1218	HB2373- 34 -LRB103 30342 KTG 56772 b HB2373 - 34 - LRB103 30342 KTG 56772 b
1219	1219	HB2373 - 34 - LRB103 30342 KTG 56772 b
1220	1220	1 and Medicaid Services of a Title XIX State Plan amendment
1221	1221	2 electing the Program of All-Inclusive Care for the Elderly
1222	1222	3 (PACE) as a State Medicaid option, as provided for by Subtitle
1223	1223	4 I (commencing with Section 4801) of Title IV of the Balanced
1224	1224	5 Budget Act of 1997 (Public Law 105-33) and Part 460
1225	1225	6 (commencing with Section 460.2) of Subchapter E of Title 42 of
1226	1226	7 the Code of Federal Regulations, PACE program services shall
1227	1227	8 become a covered benefit of the medical assistance program,
1228	1228	9 subject to criteria established in accordance with all
1229	1229	10 applicable laws.
1230	1230	11 Notwithstanding any other provision of this Code,
1231	1231	12 community-based pediatric palliative care from a trained
1232	1232	13 interdisciplinary team shall be covered under the medical
1233	1233	14 assistance program as provided in Section 15 of the Pediatric
1234	1234	15 Palliative Care Act.
1235	1235	16 Notwithstanding any other provision of this Code, within
1236	1236	17 12 months after June 2, 2022 (the effective date of Public Act
1237	1237	18 102-1037) this amendatory Act of the 102nd General Assembly
1238	1238	19 and subject to federal approval, acupuncture services
1239	1239	20 performed by an acupuncturist licensed under the Acupuncture
1240	1240	21 Practice Act who is acting within the scope of his or her
1241	1241	22 license shall be covered under the medical assistance program.
1242	1242	23 The Department shall apply for any federal waiver or State
1243	1243	24 Plan amendment, if required, to implement this paragraph. The
1244	1244	25 Department may adopt any rules, including standards and
1245	1245	26 criteria, necessary to implement this paragraph.
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
1251	1251	HB2373 - 34 - LRB103 30342 KTG 56772 b
1252	1252
1253	1253
1254	1254	HB2373- 35 -LRB103 30342 KTG 56772 b HB2373 - 35 - LRB103 30342 KTG 56772 b
1255	1255	HB2373 - 35 - LRB103 30342 KTG 56772 b
1256	1256	1 Notwithstanding any other provision of this Code,
1257	1257	2 treatment for a hoarding disorder as defined in the Diagnostic
1258	1258	3 and Statistical Manual of Mental Disorders, Fifth Edition
1259	1259	4 (DSM-5), shall be covered under the medical assistance program
1260	1260	5 for persons who are otherwise eligible for medical assistance
1261	1261	6 under this Article.
1262	1262	7 (Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
1263	1263	8 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1264	1264	9 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1265	1265	10 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
1266	1266	11 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1267	1267	12 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
1268	1268	13 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1269	1269	14 1-1-23; revised 2-5-23.)
1270	1270
1271	1271
1272	1272
1273	1273
1274	1274
1275	1275	HB2373 - 35 - LRB103 30342 KTG 56772 b