Illinois 2023-2024 Regular Session

Illinois House Bill HB4759 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 HB4759 Introduced , by Rep. Tracy Katz Muhl SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that certain self-measure blood pressure (SMBP) monitoring services involving patient education and training on the set-up and use of a SMBP devise and self-measurement data collection shall be covered and reimbursed under the medical assistance program. LRB103 38245 KTG 68380 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4759 Introduced , by Rep. Tracy Katz Muhl SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that certain self-measure blood pressure (SMBP) monitoring services involving patient education and training on the set-up and use of a SMBP devise and self-measurement data collection shall be covered and reimbursed under the medical assistance program. LRB103 38245 KTG 68380 b LRB103 38245 KTG 68380 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4759 Introduced , by Rep. Tracy Katz Muhl SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 305 ILCS 5/5-5
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5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that certain self-measure blood pressure (SMBP) monitoring services involving patient education and training on the set-up and use of a SMBP devise and self-measurement data collection shall be covered and reimbursed under the medical assistance program.
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8	8	A BILL FOR
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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)
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
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4759 Introduced , by Rep. Tracy Katz Muhl SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5 305 ILCS 5/5-5
39	39	305 ILCS 5/5-5
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that certain self-measure blood pressure (SMBP) monitoring services involving patient education and training on the set-up and use of a SMBP devise and self-measurement data collection shall be covered and reimbursed under the medical assistance program.
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43	43	A BILL FOR
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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 breast tomosynthesis.
415	415	24 The Department shall convene an expert panel including
416	416	25 representatives of hospitals, free-standing mammography
417	417	26 facilities, and doctors, including radiologists, to establish
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428	428	1 quality standards for mammography.
429	429	2 On and after January 1, 2017, providers participating in a
430	430	3 breast cancer treatment quality improvement program approved
431	431	4 by the Department shall be reimbursed for breast cancer
432	432	5 treatment at a rate that is no lower than 95% of the Medicare
433	433	6 program's rates for the data elements included in the breast
434	434	7 cancer treatment quality program.
435	435	8 The Department shall convene an expert panel, including
436	436	9 representatives of hospitals, free-standing breast cancer
437	437	10 treatment centers, breast cancer quality organizations, and
438	438	11 doctors, including breast surgeons, reconstructive breast
439	439	12 surgeons, oncologists, and primary care providers to establish
440	440	13 quality standards for breast cancer treatment.
441	441	14 Subject to federal approval, the Department shall
442	442	15 establish a rate methodology for mammography at federally
443	443	16 qualified health centers and other encounter-rate clinics.
444	444	17 These clinics or centers may also collaborate with other
445	445	18 hospital-based mammography facilities. By January 1, 2016, the
446	446	19 Department shall report to the General Assembly on the status
447	447	20 of the provision set forth in this paragraph.
448	448	21 The Department shall establish a methodology to remind
449	449	22 individuals who are age-appropriate for screening mammography,
450	450	23 but who have not received a mammogram within the previous 18
451	451	24 months, of the importance and benefit of screening
452	452	25 mammography. The Department shall work with experts in breast
453	453	26 cancer outreach and patient navigation to optimize these
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464	464	1 reminders and shall establish a methodology for evaluating
465	465	2 their effectiveness and modifying the methodology based on the
466	466	3 evaluation.
467	467	4 The Department shall establish a performance goal for
468	468	5 primary care providers with respect to their female patients
469	469	6 over age 40 receiving an annual mammogram. This performance
470	470	7 goal shall be used to provide additional reimbursement in the
471	471	8 form of a quality performance bonus to primary care providers
472	472	9 who meet that goal.
473	473	10 The Department shall devise a means of case-managing or
474	474	11 patient navigation for beneficiaries diagnosed with breast
475	475	12 cancer. This program shall initially operate as a pilot
476	476	13 program in areas of the State with the highest incidence of
477	477	14 mortality related to breast cancer. At least one pilot program
478	478	15 site shall be in the metropolitan Chicago area and at least one
479	479	16 site shall be outside the metropolitan Chicago area. On or
480	480	17 after July 1, 2016, the pilot program shall be expanded to
481	481	18 include one site in western Illinois, one site in southern
482	482	19 Illinois, one site in central Illinois, and 4 sites within
483	483	20 metropolitan Chicago. An evaluation of the pilot program shall
484	484	21 be carried out measuring health outcomes and cost of care for
485	485	22 those served by the pilot program compared to similarly
486	486	23 situated patients who are not served by the pilot program.
487	487	24 The Department shall require all networks of care to
488	488	25 develop a means either internally or by contract with experts
489	489	26 in navigation and community outreach to navigate cancer
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500	500	1 patients to comprehensive care in a timely fashion. The
501	501	2 Department shall require all networks of care to include
502	502	3 access for patients diagnosed with cancer to at least one
503	503	4 academic commission on cancer-accredited cancer program as an
504	504	5 in-network covered benefit.
505	505	6 The Department shall provide coverage and reimbursement
506	506	7 for a human papillomavirus (HPV) vaccine that is approved for
507	507	8 marketing by the federal Food and Drug Administration for all
508	508	9 persons between the ages of 9 and 45. Subject to federal
509	509	10 approval, the Department shall provide coverage and
510	510	11 reimbursement for a human papillomavirus (HPV) vaccine for
511	511	12 persons of the age of 46 and above who have been diagnosed with
512	512	13 cervical dysplasia with a high risk of recurrence or
513	513	14 progression. The Department shall disallow any
514	514	15 preauthorization requirements for the administration of the
515	515	16 human papillomavirus (HPV) vaccine.
516	516	17 On or after July 1, 2022, individuals who are otherwise
517	517	18 eligible for medical assistance under this Article shall
518	518	19 receive coverage for perinatal depression screenings for the
519	519	20 12-month period beginning on the last day of their pregnancy.
520	520	21 Medical assistance coverage under this paragraph shall be
521	521	22 conditioned on the use of a screening instrument approved by
522	522	23 the Department.
523	523	24 Any medical or health care provider shall immediately
524	524	25 recommend, to any pregnant individual who is being provided
525	525	26 prenatal services and is suspected of having a substance use
526	526
527	527
528	528
529	529
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536	536	1 disorder as defined in the Substance Use Disorder Act,
537	537	2 referral to a local substance use disorder treatment program
538	538	3 licensed by the Department of Human Services or to a licensed
539	539	4 hospital which provides substance abuse treatment services.
540	540	5 The Department of Healthcare and Family Services shall assure
541	541	6 coverage for the cost of treatment of the drug abuse or
542	542	7 addiction for pregnant recipients in accordance with the
543	543	8 Illinois Medicaid Program in conjunction with the Department
544	544	9 of Human Services.
545	545	10 All medical providers providing medical assistance to
546	546	11 pregnant individuals under this Code shall receive information
547	547	12 from the Department on the availability of services under any
548	548	13 program providing case management services for addicted
549	549	14 individuals, including information on appropriate referrals
550	550	15 for other social services that may be needed by addicted
551	551	16 individuals in addition to treatment for addiction.
552	552	17 The Illinois Department, in cooperation with the
553	553	18 Departments of Human Services (as successor to the Department
554	554	19 of Alcoholism and Substance Abuse) and Public Health, through
555	555	20 a public awareness campaign, may provide information
556	556	21 concerning treatment for alcoholism and drug abuse and
557	557	22 addiction, prenatal health care, and other pertinent programs
558	558	23 directed at reducing the number of drug-affected infants born
559	559	24 to recipients of medical assistance.
560	560	25 Neither the Department of Healthcare and Family Services
561	561	26 nor the Department of Human Services shall sanction the
562	562
563	563
564	564
565	565
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569	569
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572	572	1 recipient solely on the basis of the recipient's substance
573	573	2 abuse.
574	574	3 The Illinois Department shall establish such regulations
575	575	4 governing the dispensing of health services under this Article
576	576	5 as it shall deem appropriate. The Department should seek the
577	577	6 advice of formal professional advisory committees appointed by
578	578	7 the Director of the Illinois Department for the purpose of
579	579	8 providing regular advice on policy and administrative matters,
580	580	9 information dissemination and educational activities for
581	581	10 medical and health care providers, and consistency in
582	582	11 procedures to the Illinois Department.
583	583	12 The Illinois Department may develop and contract with
584	584	13 Partnerships of medical providers to arrange medical services
585	585	14 for persons eligible under Section 5-2 of this Code.
586	586	15 Implementation of this Section may be by demonstration
587	587	16 projects in certain geographic areas. The Partnership shall be
588	588	17 represented by a sponsor organization. The Department, by
589	589	18 rule, shall develop qualifications for sponsors of
590	590	19 Partnerships. Nothing in this Section shall be construed to
591	591	20 require that the sponsor organization be a medical
592	592	21 organization.
593	593	22 The sponsor must negotiate formal written contracts with
594	594	23 medical providers for physician services, inpatient and
595	595	24 outpatient hospital care, home health services, treatment for
596	596	25 alcoholism and substance abuse, and other services determined
597	597	26 necessary by the Illinois Department by rule for delivery by
598	598
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601	601
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608	608	1 Partnerships. Physician services must include prenatal and
609	609	2 obstetrical care. The Illinois Department shall reimburse
610	610	3 medical services delivered by Partnership providers to clients
611	611	4 in target areas according to provisions of this Article and
612	612	5 the Illinois Health Finance Reform Act, except that:
613	613	6 (1) Physicians participating in a Partnership and
614	614	7 providing certain services, which shall be determined by
615	615	8 the Illinois Department, to persons in areas covered by
616	616	9 the Partnership may receive an additional surcharge for
617	617	10 such services.
618	618	11 (2) The Department may elect to consider and negotiate
619	619	12 financial incentives to encourage the development of
620	620	13 Partnerships and the efficient delivery of medical care.
621	621	14 (3) Persons receiving medical services through
622	622	15 Partnerships may receive medical and case management
623	623	16 services above the level usually offered through the
624	624	17 medical assistance program.
625	625	18 Medical providers shall be required to meet certain
626	626	19 qualifications to participate in Partnerships to ensure the
627	627	20 delivery of high quality medical services. These
628	628	21 qualifications shall be determined by rule of the Illinois
629	629	22 Department and may be higher than qualifications for
630	630	23 participation in the medical assistance program. Partnership
631	631	24 sponsors may prescribe reasonable additional qualifications
632	632	25 for participation by medical providers, only with the prior
633	633	26 written approval of the Illinois Department.
634	634
635	635
636	636
637	637
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644	644	1 Nothing in this Section shall limit the free choice of
645	645	2 practitioners, hospitals, and other providers of medical
646	646	3 services by clients. In order to ensure patient freedom of
647	647	4 choice, the Illinois Department shall immediately promulgate
648	648	5 all rules and take all other necessary actions so that
649	649	6 provided services may be accessed from therapeutically
650	650	7 certified optometrists to the full extent of the Illinois
651	651	8 Optometric Practice Act of 1987 without discriminating between
652	652	9 service providers.
653	653	10 The Department shall apply for a waiver from the United
654	654	11 States Health Care Financing Administration to allow for the
655	655	12 implementation of Partnerships under this Section.
656	656	13 The Illinois Department shall require health care
657	657	14 providers to maintain records that document the medical care
658	658	15 and services provided to recipients of Medical Assistance
659	659	16 under this Article. Such records must be retained for a period
660	660	17 of not less than 6 years from the date of service or as
661	661	18 provided by applicable State law, whichever period is longer,
662	662	19 except that if an audit is initiated within the required
663	663	20 retention period then the records must be retained until the
664	664	21 audit is completed and every exception is resolved. The
665	665	22 Illinois Department shall require health care providers to
666	666	23 make available, when authorized by the patient, in writing,
667	667	24 the medical records in a timely fashion to other health care
668	668	25 providers who are treating or serving persons eligible for
669	669	26 Medical Assistance under this Article. All dispensers of
670	670
671	671
672	672
673	673
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680	680	1 medical services shall be required to maintain and retain
681	681	2 business and professional records sufficient to fully and
682	682	3 accurately document the nature, scope, details and receipt of
683	683	4 the health care provided to persons eligible for medical
684	684	5 assistance under this Code, in accordance with regulations
685	685	6 promulgated by the Illinois Department. The rules and
686	686	7 regulations shall require that proof of the receipt of
687	687	8 prescription drugs, dentures, prosthetic devices and
688	688	9 eyeglasses by eligible persons under this Section accompany
689	689	10 each claim for reimbursement submitted by the dispenser of
690	690	11 such medical services. No such claims for reimbursement shall
691	691	12 be approved for payment by the Illinois Department without
692	692	13 such proof of receipt, unless the Illinois Department shall
693	693	14 have put into effect and shall be operating a system of
694	694	15 post-payment audit and review which shall, on a sampling
695	695	16 basis, be deemed adequate by the Illinois Department to assure
696	696	17 that such drugs, dentures, prosthetic devices and eyeglasses
697	697	18 for which payment is being made are actually being received by
698	698	19 eligible recipients. Within 90 days after September 16, 1984
699	699	20 (the effective date of Public Act 83-1439), the Illinois
700	700	21 Department shall establish a current list of acquisition costs
701	701	22 for all prosthetic devices and any other items recognized as
702	702	23 medical equipment and supplies reimbursable under this Article
703	703	24 and shall update such list on a quarterly basis, except that
704	704	25 the acquisition costs of all prescription drugs shall be
705	705	26 updated no less frequently than every 30 days as required by
706	706
707	707
708	708
709	709
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716	716	1 Section 5-5.12.
717	717	2 Notwithstanding any other law to the contrary, the
718	718	3 Illinois Department shall, within 365 days after July 22, 2013
719	719	4 (the effective date of Public Act 98-104), establish
720	720	5 procedures to permit skilled care facilities licensed under
721	721	6 the Nursing Home Care Act to submit monthly billing claims for
722	722	7 reimbursement purposes. Following development of these
723	723	8 procedures, the Department shall, by July 1, 2016, test the
724	724	9 viability of the new system and implement any necessary
725	725	10 operational or structural changes to its information
726	726	11 technology platforms in order to allow for the direct
727	727	12 acceptance and payment of nursing home claims.
728	728	13 Notwithstanding any other law to the contrary, the
729	729	14 Illinois Department shall, within 365 days after August 15,
730	730	15 2014 (the effective date of Public Act 98-963), establish
731	731	16 procedures to permit ID/DD facilities licensed under the ID/DD
732	732	17 Community Care Act and MC/DD facilities licensed under the
733	733	18 MC/DD Act to submit monthly billing claims for reimbursement
734	734	19 purposes. Following development of these procedures, the
735	735	20 Department shall have an additional 365 days to test the
736	736	21 viability of the new system and to ensure that any necessary
737	737	22 operational or structural changes to its information
738	738	23 technology platforms are implemented.
739	739	24 The Illinois Department shall require all dispensers of
740	740	25 medical services, other than an individual practitioner or
741	741	26 group of practitioners, desiring to participate in the Medical
742	742
743	743
744	744
745	745
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752	752	1 Assistance program established under this Article to disclose
753	753	2 all financial, beneficial, ownership, equity, surety or other
754	754	3 interests in any and all firms, corporations, partnerships,
755	755	4 associations, business enterprises, joint ventures, agencies,
756	756	5 institutions or other legal entities providing any form of
757	757	6 health care services in this State under this Article.
758	758	7 The Illinois Department may require that all dispensers of
759	759	8 medical services desiring to participate in the medical
760	760	9 assistance program established under this Article disclose,
761	761	10 under such terms and conditions as the Illinois Department may
762	762	11 by rule establish, all inquiries from clients and attorneys
763	763	12 regarding medical bills paid by the Illinois Department, which
764	764	13 inquiries could indicate potential existence of claims or
765	765	14 liens for the Illinois Department.
766	766	15 Enrollment of a vendor shall be subject to a provisional
767	767	16 period and shall be conditional for one year. During the
768	768	17 period of conditional enrollment, the Department may terminate
769	769	18 the vendor's eligibility to participate in, or may disenroll
770	770	19 the vendor from, the medical assistance program without cause.
771	771	20 Unless otherwise specified, such termination of eligibility or
772	772	21 disenrollment is not subject to the Department's hearing
773	773	22 process. However, a disenrolled vendor may reapply without
774	774	23 penalty.
775	775	24 The Department has the discretion to limit the conditional
776	776	25 enrollment period for vendors based upon the category of risk
777	777	26 of the vendor.
778	778
779	779
780	780
781	781
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784	784
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788	788	1 Prior to enrollment and during the conditional enrollment
789	789	2 period in the medical assistance program, all vendors shall be
790	790	3 subject to enhanced oversight, screening, and review based on
791	791	4 the risk of fraud, waste, and abuse that is posed by the
792	792	5 category of risk of the vendor. The Illinois Department shall
793	793	6 establish the procedures for oversight, screening, and review,
794	794	7 which may include, but need not be limited to: criminal and
795	795	8 financial background checks; fingerprinting; license,
796	796	9 certification, and authorization verifications; unscheduled or
797	797	10 unannounced site visits; database checks; prepayment audit
798	798	11 reviews; audits; payment caps; payment suspensions; and other
799	799	12 screening as required by federal or State law.
800	800	13 The Department shall define or specify the following: (i)
801	801	14 by provider notice, the "category of risk of the vendor" for
802	802	15 each type of vendor, which shall take into account the level of
803	803	16 screening applicable to a particular category of vendor under
804	804	17 federal law and regulations; (ii) by rule or provider notice,
805	805	18 the maximum length of the conditional enrollment period for
806	806	19 each category of risk of the vendor; and (iii) by rule, the
807	807	20 hearing rights, if any, afforded to a vendor in each category
808	808	21 of risk of the vendor that is terminated or disenrolled during
809	809	22 the conditional enrollment period.
810	810	23 To be eligible for payment consideration, a vendor's
811	811	24 payment claim or bill, either as an initial claim or as a
812	812	25 resubmitted claim following prior rejection, must be received
813	813	26 by the Illinois Department, or its fiscal intermediary, no
814	814
815	815
816	816
817	817
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820	820
821	821
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824	824	1 later than 180 days after the latest date on the claim on which
825	825	2 medical goods or services were provided, with the following
826	826	3 exceptions:
827	827	4 (1) In the case of a provider whose enrollment is in
828	828	5 process by the Illinois Department, the 180-day period
829	829	6 shall not begin until the date on the written notice from
830	830	7 the Illinois Department that the provider enrollment is
831	831	8 complete.
832	832	9 (2) In the case of errors attributable to the Illinois
833	833	10 Department or any of its claims processing intermediaries
834	834	11 which result in an inability to receive, process, or
835	835	12 adjudicate a claim, the 180-day period shall not begin
836	836	13 until the provider has been notified of the error.
837	837	14 (3) In the case of a provider for whom the Illinois
838	838	15 Department initiates the monthly billing process.
839	839	16 (4) In the case of a provider operated by a unit of
840	840	17 local government with a population exceeding 3,000,000
841	841	18 when local government funds finance federal participation
842	842	19 for claims payments.
843	843	20 For claims for services rendered during a period for which
844	844	21 a recipient received retroactive eligibility, claims must be
845	845	22 filed within 180 days after the Department determines the
846	846	23 applicant is eligible. For claims for which the Illinois
847	847	24 Department is not the primary payer, claims must be submitted
848	848	25 to the Illinois Department within 180 days after the final
849	849	26 adjudication by the primary payer.
850	850
851	851
852	852
853	853
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856	856
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860	860	1 In the case of long term care facilities, within 120
861	861	2 calendar days of receipt by the facility of required
862	862	3 prescreening information, new admissions with associated
863	863	4 admission documents shall be submitted through the Medical
864	864	5 Electronic Data Interchange (MEDI) or the Recipient
865	865	6 Eligibility Verification (REV) System or shall be submitted
866	866	7 directly to the Department of Human Services using required
867	867	8 admission forms. Effective September 1, 2014, admission
868	868	9 documents, including all prescreening information, must be
869	869	10 submitted through MEDI or REV. Confirmation numbers assigned
870	870	11 to an accepted transaction shall be retained by a facility to
871	871	12 verify timely submittal. Once an admission transaction has
872	872	13 been completed, all resubmitted claims following prior
873	873	14 rejection are subject to receipt no later than 180 days after
874	874	15 the admission transaction has been completed.
875	875	16 Claims that are not submitted and received in compliance
876	876	17 with the foregoing requirements shall not be eligible for
877	877	18 payment under the medical assistance program, and the State
878	878	19 shall have no liability for payment of those claims.
879	879	20 To the extent consistent with applicable information and
880	880	21 privacy, security, and disclosure laws, State and federal
881	881	22 agencies and departments shall provide the Illinois Department
882	882	23 access to confidential and other information and data
883	883	24 necessary to perform eligibility and payment verifications and
884	884	25 other Illinois Department functions. This includes, but is not
885	885	26 limited to: information pertaining to licensure;
886	886
887	887
888	888
889	889
890	890
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892	892
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896	896	1 certification; earnings; immigration status; citizenship; wage
897	897	2 reporting; unearned and earned income; pension income;
898	898	3 employment; supplemental security income; social security
899	899	4 numbers; National Provider Identifier (NPI) numbers; the
900	900	5 National Practitioner Data Bank (NPDB); program and agency
901	901	6 exclusions; taxpayer identification numbers; tax delinquency;
902	902	7 corporate information; and death records.
903	903	8 The Illinois Department shall enter into agreements with
904	904	9 State agencies and departments, and is authorized to enter
905	905	10 into agreements with federal agencies and departments, under
906	906	11 which such agencies and departments shall share data necessary
907	907	12 for medical assistance program integrity functions and
908	908	13 oversight. The Illinois Department shall develop, in
909	909	14 cooperation with other State departments and agencies, and in
910	910	15 compliance with applicable federal laws and regulations,
911	911	16 appropriate and effective methods to share such data. At a
912	912	17 minimum, and to the extent necessary to provide data sharing,
913	913	18 the Illinois Department shall enter into agreements with State
914	914	19 agencies and departments, and is authorized to enter into
915	915	20 agreements with federal agencies and departments, including,
916	916	21 but not limited to: the Secretary of State; the Department of
917	917	22 Revenue; the Department of Public Health; the Department of
918	918	23 Human Services; and the Department of Financial and
919	919	24 Professional Regulation.
920	920	25 Beginning in fiscal year 2013, the Illinois Department
921	921	26 shall set forth a request for information to identify the
922	922
923	923
924	924
925	925
926	926
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928	928
929	929
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932	932	1 benefits of a pre-payment, post-adjudication, and post-edit
933	933	2 claims system with the goals of streamlining claims processing
934	934	3 and provider reimbursement, reducing the number of pending or
935	935	4 rejected claims, and helping to ensure a more transparent
936	936	5 adjudication process through the utilization of: (i) provider
937	937	6 data verification and provider screening technology; and (ii)
938	938	7 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
939	939	8 post-adjudicated predictive modeling with an integrated case
940	940	9 management system with link analysis. Such a request for
941	941	10 information shall not be considered as a request for proposal
942	942	11 or as an obligation on the part of the Illinois Department to
943	943	12 take any action or acquire any products or services.
944	944	13 The Illinois Department shall establish policies,
945	945	14 procedures, standards and criteria by rule for the
946	946	15 acquisition, repair and replacement of orthotic and prosthetic
947	947	16 devices and durable medical equipment. Such rules shall
948	948	17 provide, but not be limited to, the following services: (1)
949	949	18 immediate repair or replacement of such devices by recipients;
950	950	19 and (2) rental, lease, purchase or lease-purchase of durable
951	951	20 medical equipment in a cost-effective manner, taking into
952	952	21 consideration the recipient's medical prognosis, the extent of
953	953	22 the recipient's needs, and the requirements and costs for
954	954	23 maintaining such equipment. Subject to prior approval, such
955	955	24 rules shall enable a recipient to temporarily acquire and use
956	956	25 alternative or substitute devices or equipment pending repairs
957	957	26 or replacements of any device or equipment previously
958	958
959	959
960	960
961	961
962	962
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964	964
965	965
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968	968	1 authorized for such recipient by the Department.
969	969	2 Notwithstanding any provision of Section 5-5f to the contrary,
970	970	3 the Department may, by rule, exempt certain replacement
971	971	4 wheelchair parts from prior approval and, for wheelchairs,
972	972	5 wheelchair parts, wheelchair accessories, and related seating
973	973	6 and positioning items, determine the wholesale price by
974	974	7 methods other than actual acquisition costs.
975	975	8 The Department shall require, by rule, all providers of
976	976	9 durable medical equipment to be accredited by an accreditation
977	977	10 organization approved by the federal Centers for Medicare and
978	978	11 Medicaid Services and recognized by the Department in order to
979	979	12 bill the Department for providing durable medical equipment to
980	980	13 recipients. No later than 15 months after the effective date
981	981	14 of the rule adopted pursuant to this paragraph, all providers
982	982	15 must meet the accreditation requirement.
983	983	16 In order to promote environmental responsibility, meet the
984	984	17 needs of recipients and enrollees, and achieve significant
985	985	18 cost savings, the Department, or a managed care organization
986	986	19 under contract with the Department, may provide recipients or
987	987	20 managed care enrollees who have a prescription or Certificate
988	988	21 of Medical Necessity access to refurbished durable medical
989	989	22 equipment under this Section (excluding prosthetic and
990	990	23 orthotic devices as defined in the Orthotics, Prosthetics, and
991	991	24 Pedorthics Practice Act and complex rehabilitation technology
992	992	25 products and associated services) through the State's
993	993	26 assistive technology program's reutilization program, using
994	994
995	995
996	996
997	997
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1001	1001
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1004	1004	1 staff with the Assistive Technology Professional (ATP)
1005	1005	2 Certification if the refurbished durable medical equipment:
1006	1006	3 (i) is available; (ii) is less expensive, including shipping
1007	1007	4 costs, than new durable medical equipment of the same type;
1008	1008	5 (iii) is able to withstand at least 3 years of use; (iv) is
1009	1009	6 cleaned, disinfected, sterilized, and safe in accordance with
1010	1010	7 federal Food and Drug Administration regulations and guidance
1011	1011	8 governing the reprocessing of medical devices in health care
1012	1012	9 settings; and (v) equally meets the needs of the recipient or
1013	1013	10 enrollee. The reutilization program shall confirm that the
1014	1014	11 recipient or enrollee is not already in receipt of the same or
1015	1015	12 similar equipment from another service provider, and that the
1016	1016	13 refurbished durable medical equipment equally meets the needs
1017	1017	14 of the recipient or enrollee. Nothing in this paragraph shall
1018	1018	15 be construed to limit recipient or enrollee choice to obtain
1019	1019	16 new durable medical equipment or place any additional prior
1020	1020	17 authorization conditions on enrollees of managed care
1021	1021	18 organizations.
1022	1022	19 The Department shall execute, relative to the nursing home
1023	1023	20 prescreening project, written inter-agency agreements with the
1024	1024	21 Department of Human Services and the Department on Aging, to
1025	1025	22 effect the following: (i) intake procedures and common
1026	1026	23 eligibility criteria for those persons who are receiving
1027	1027	24 non-institutional services; and (ii) the establishment and
1028	1028	25 development of non-institutional services in areas of the
1029	1029	26 State where they are not currently available or are
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB4759 - 28 - LRB103 38245 KTG 68380 b
1036	1036
1037	1037
1038	1038	HB4759- 29 -LRB103 38245 KTG 68380 b HB4759 - 29 - LRB103 38245 KTG 68380 b
1039	1039	HB4759 - 29 - LRB103 38245 KTG 68380 b
1040	1040	1 undeveloped; and (iii) notwithstanding any other provision of
1041	1041	2 law, subject to federal approval, on and after July 1, 2012, an
1042	1042	3 increase in the determination of need (DON) scores from 29 to
1043	1043	4 37 for applicants for institutional and home and
1044	1044	5 community-based long term care; if and only if federal
1045	1045	6 approval is not granted, the Department may, in conjunction
1046	1046	7 with other affected agencies, implement utilization controls
1047	1047	8 or changes in benefit packages to effectuate a similar savings
1048	1048	9 amount for this population; and (iv) no later than July 1,
1049	1049	10 2013, minimum level of care eligibility criteria for
1050	1050	11 institutional and home and community-based long term care; and
1051	1051	12 (v) no later than October 1, 2013, establish procedures to
1052	1052	13 permit long term care providers access to eligibility scores
1053	1053	14 for individuals with an admission date who are seeking or
1054	1054	15 receiving services from the long term care provider. In order
1055	1055	16 to select the minimum level of care eligibility criteria, the
1056	1056	17 Governor shall establish a workgroup that includes affected
1057	1057	18 agency representatives and stakeholders representing the
1058	1058	19 institutional and home and community-based long term care
1059	1059	20 interests. This Section shall not restrict the Department from
1060	1060	21 implementing lower level of care eligibility criteria for
1061	1061	22 community-based services in circumstances where federal
1062	1062	23 approval has been granted.
1063	1063	24 The Illinois Department shall develop and operate, in
1064	1064	25 cooperation with other State Departments and agencies and in
1065	1065	26 compliance with applicable federal laws and regulations,
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB4759 - 29 - LRB103 38245 KTG 68380 b
1072	1072
1073	1073
1074	1074	HB4759- 30 -LRB103 38245 KTG 68380 b HB4759 - 30 - LRB103 38245 KTG 68380 b
1075	1075	HB4759 - 30 - LRB103 38245 KTG 68380 b
1076	1076	1 appropriate and effective systems of health care evaluation
1077	1077	2 and programs for monitoring of utilization of health care
1078	1078	3 services and facilities, as it affects persons eligible for
1079	1079	4 medical assistance under this Code.
1080	1080	5 The Illinois Department shall report annually to the
1081	1081	6 General Assembly, no later than the second Friday in April of
1082	1082	7 1979 and each year thereafter, in regard to:
1083	1083	8 (a) actual statistics and trends in utilization of
1084	1084	9 medical services by public aid recipients;
1085	1085	10 (b) actual statistics and trends in the provision of
1086	1086	11 the various medical services by medical vendors;
1087	1087	12 (c) current rate structures and proposed changes in
1088	1088	13 those rate structures for the various medical vendors; and
1089	1089	14 (d) efforts at utilization review and control by the
1090	1090	15 Illinois Department.
1091	1091	16 The period covered by each report shall be the 3 years
1092	1092	17 ending on the June 30 prior to the report. The report shall
1093	1093	18 include suggested legislation for consideration by the General
1094	1094	19 Assembly. The requirement for reporting to the General
1095	1095	20 Assembly shall be satisfied by filing copies of the report as
1096	1096	21 required by Section 3.1 of the General Assembly Organization
1097	1097	22 Act, and filing such additional copies with the State
1098	1098	23 Government Report Distribution Center for the General Assembly
1099	1099	24 as is required under paragraph (t) of Section 7 of the State
1100	1100	25 Library Act.
1101	1101	26 Rulemaking authority to implement Public Act 95-1045, if
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB4759 - 30 - LRB103 38245 KTG 68380 b
1108	1108
1109	1109
1110	1110	HB4759- 31 -LRB103 38245 KTG 68380 b HB4759 - 31 - LRB103 38245 KTG 68380 b
1111	1111	HB4759 - 31 - LRB103 38245 KTG 68380 b
1112	1112	1 any, is conditioned on the rules being adopted in accordance
1113	1113	2 with all provisions of the Illinois Administrative Procedure
1114	1114	3 Act and all rules and procedures of the Joint Committee on
1115	1115	4 Administrative Rules; any purported rule not so adopted, for
1116	1116	5 whatever reason, is unauthorized.
1117	1117	6 On and after July 1, 2012, the Department shall reduce any
1118	1118	7 rate of reimbursement for services or other payments or alter
1119	1119	8 any methodologies authorized by this Code to reduce any rate
1120	1120	9 of reimbursement for services or other payments in accordance
1121	1121	10 with Section 5-5e.
1122	1122	11 Because kidney transplantation can be an appropriate,
1123	1123	12 cost-effective alternative to renal dialysis when medically
1124	1124	13 necessary and notwithstanding the provisions of Section 1-11
1125	1125	14 of this Code, beginning October 1, 2014, the Department shall
1126	1126	15 cover kidney transplantation for noncitizens with end-stage
1127	1127	16 renal disease who are not eligible for comprehensive medical
1128	1128	17 benefits, who meet the residency requirements of Section 5-3
1129	1129	18 of this Code, and who would otherwise meet the financial
1130	1130	19 requirements of the appropriate class of eligible persons
1131	1131	20 under Section 5-2 of this Code. To qualify for coverage of
1132	1132	21 kidney transplantation, such person must be receiving
1133	1133	22 emergency renal dialysis services covered by the Department.
1134	1134	23 Providers under this Section shall be prior approved and
1135	1135	24 certified by the Department to perform kidney transplantation
1136	1136	25 and the services under this Section shall be limited to
1137	1137	26 services associated with kidney transplantation.
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB4759 - 31 - LRB103 38245 KTG 68380 b
1144	1144
1145	1145
1146	1146	HB4759- 32 -LRB103 38245 KTG 68380 b HB4759 - 32 - LRB103 38245 KTG 68380 b
1147	1147	HB4759 - 32 - LRB103 38245 KTG 68380 b
1148	1148	1 Notwithstanding any other provision of this Code to the
1149	1149	2 contrary, on or after July 1, 2015, all FDA approved forms of
1150	1150	3 medication assisted treatment prescribed for the treatment of
1151	1151	4 alcohol dependence or treatment of opioid dependence shall be
1152	1152	5 covered under both fee-for-service fee for service and managed
1153	1153	6 care medical assistance programs for persons who are otherwise
1154	1154	7 eligible for medical assistance under this Article and shall
1155	1155	8 not be subject to any (1) utilization control, other than
1156	1156	9 those established under the American Society of Addiction
1157	1157	10 Medicine patient placement criteria, (2) prior authorization
1158	1158	11 mandate, or (3) lifetime restriction limit mandate.
1159	1159	12 On or after July 1, 2015, opioid antagonists prescribed
1160	1160	13 for the treatment of an opioid overdose, including the
1161	1161	14 medication product, administration devices, and any pharmacy
1162	1162	15 fees or hospital fees related to the dispensing, distribution,
1163	1163	16 and administration of the opioid antagonist, shall be covered
1164	1164	17 under the medical assistance program for persons who are
1165	1165	18 otherwise eligible for medical assistance under this Article.
1166	1166	19 As used in this Section, "opioid antagonist" means a drug that
1167	1167	20 binds to opioid receptors and blocks or inhibits the effect of
1168	1168	21 opioids acting on those receptors, including, but not limited
1169	1169	22 to, naloxone hydrochloride or any other similarly acting drug
1170	1170	23 approved by the U.S. Food and Drug Administration. The
1171	1171	24 Department shall not impose a copayment on the coverage
1172	1172	25 provided for naloxone hydrochloride under the medical
1173	1173	26 assistance program.
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB4759 - 32 - LRB103 38245 KTG 68380 b
1180	1180
1181	1181
1182	1182	HB4759- 33 -LRB103 38245 KTG 68380 b HB4759 - 33 - LRB103 38245 KTG 68380 b
1183	1183	HB4759 - 33 - LRB103 38245 KTG 68380 b
1184	1184	1 Upon federal approval, the Department shall provide
1185	1185	2 coverage and reimbursement for all drugs that are approved for
1186	1186	3 marketing by the federal Food and Drug Administration and that
1187	1187	4 are recommended by the federal Public Health Service or the
1188	1188	5 United States Centers for Disease Control and Prevention for
1189	1189	6 pre-exposure prophylaxis and related pre-exposure prophylaxis
1190	1190	7 services, including, but not limited to, HIV and sexually
1191	1191	8 transmitted infection screening, treatment for sexually
1192	1192	9 transmitted infections, medical monitoring, assorted labs, and
1193	1193	10 counseling to reduce the likelihood of HIV infection among
1194	1194	11 individuals who are not infected with HIV but who are at high
1195	1195	12 risk of HIV infection.
1196	1196	13 A federally qualified health center, as defined in Section
1197	1197	14 1905(l)(2)(B) of the federal Social Security Act, shall be
1198	1198	15 reimbursed by the Department in accordance with the federally
1199	1199	16 qualified health center's encounter rate for services provided
1200	1200	17 to medical assistance recipients that are performed by a
1201	1201	18 dental hygienist, as defined under the Illinois Dental
1202	1202	19 Practice Act, working under the general supervision of a
1203	1203	20 dentist and employed by a federally qualified health center.
1204	1204	21 Within 90 days after October 8, 2021 (the effective date
1205	1205	22 of Public Act 102-665), the Department shall seek federal
1206	1206	23 approval of a State Plan amendment to expand coverage for
1207	1207	24 family planning services that includes presumptive eligibility
1208	1208	25 to individuals whose income is at or below 208% of the federal
1209	1209	26 poverty level. Coverage under this Section shall be effective
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB4759 - 33 - LRB103 38245 KTG 68380 b
1216	1216
1217	1217
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1220	1220	1 beginning no later than December 1, 2022.
1221	1221	2 Subject to approval by the federal Centers for Medicare
1222	1222	3 and Medicaid Services of a Title XIX State Plan amendment
1223	1223	4 electing the Program of All-Inclusive Care for the Elderly
1224	1224	5 (PACE) as a State Medicaid option, as provided for by Subtitle
1225	1225	6 I (commencing with Section 4801) of Title IV of the Balanced
1226	1226	7 Budget Act of 1997 (Public Law 105-33) and Part 460
1227	1227	8 (commencing with Section 460.2) of Subchapter E of Title 42 of
1228	1228	9 the Code of Federal Regulations, PACE program services shall
1229	1229	10 become a covered benefit of the medical assistance program,
1230	1230	11 subject to criteria established in accordance with all
1231	1231	12 applicable laws.
1232	1232	13 Notwithstanding any other provision of this Code,
1233	1233	14 community-based pediatric palliative care from a trained
1234	1234	15 interdisciplinary team shall be covered under the medical
1235	1235	16 assistance program as provided in Section 15 of the Pediatric
1236	1236	17 Palliative Care Act.
1237	1237	18 Notwithstanding any other provision of this Code, within
1238	1238	19 12 months after June 2, 2022 (the effective date of Public Act
1239	1239	20 102-1037) and subject to federal approval, acupuncture
1240	1240	21 services performed by an acupuncturist licensed under the
1241	1241	22 Acupuncture Practice Act who is acting within the scope of his
1242	1242	23 or her license shall be covered under the medical assistance
1243	1243	24 program. The Department shall apply for any federal waiver or
1244	1244	25 State Plan amendment, if required, to implement this
1245	1245	26 paragraph. The Department may adopt any rules, including
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
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1252	1252
1253	1253
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1256	1256	1 standards and criteria, necessary to implement this paragraph.
1257	1257	2 Notwithstanding any other provision of this Code, the
1258	1258	3 medical assistance program shall, subject to appropriation and
1259	1259	4 federal approval, reimburse hospitals for costs associated
1260	1260	5 with a newborn screening test for the presence of
1261	1261	6 metachromatic leukodystrophy, as required under the Newborn
1262	1262	7 Metabolic Screening Act, at a rate not less than the fee
1263	1263	8 charged by the Department of Public Health. The Department
1264	1264	9 shall seek federal approval before the implementation of the
1265	1265	10 newborn screening test fees by the Department of Public
1266	1266	11 Health.
1267	1267	12 Notwithstanding any other provision of this Code,
1268	1268	13 beginning on January 1, 2024, subject to federal approval,
1269	1269	14 cognitive assessment and care planning services provided to a
1270	1270	15 person who experiences signs or symptoms of cognitive
1271	1271	16 impairment, as defined by the Diagnostic and Statistical
1272	1272	17 Manual of Mental Disorders, Fifth Edition, shall be covered
1273	1273	18 under the medical assistance program for persons who are
1274	1274	19 otherwise eligible for medical assistance under this Article.
1275	1275	20 Notwithstanding any other provision of this Code,
1276	1276	21 medically necessary reconstructive services that are intended
1277	1277	22 to restore physical appearance shall be covered under the
1278	1278	23 medical assistance program for persons who are otherwise
1279	1279	24 eligible for medical assistance under this Article. As used in
1280	1280	25 this paragraph, "reconstructive services" means treatments
1281	1281	26 performed on structures of the body damaged by trauma to
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
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1288	1288
1289	1289
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1291	1291	HB4759 - 36 - LRB103 38245 KTG 68380 b
1292	1292	1 restore physical appearance.
1293	1293	2 Notwithstanding any other provision of this Code, the
1294	1294	3 following CPT codes and self-measure blood pressure monitoring
1295	1295	4 services shall be covered and reimbursed under the medical
1296	1296	5 assistance program for persons who are otherwise eligible for
1297	1297	6 medical assistance under this Article:
1298	1298	7 (1) CPT code 99473: for patient education and training
1299	1299	8 services on the set-up and use of a self-measure blood
1300	1300	9 pressure measurement devise validated for clinical
1301	1301	10 accuracy and device calibration; and
1302	1302	11 (2) CPT code 99474: for separate self-measurements of
1303	1303	12 2 readings and the collection of data reports by the
1304	1304	13 patient or caregiver to the healthcare provider in order
1305	1305	14 to communicate blood pressure readings and create or
1306	1306	15 modify treatment plans.
1307	1307	16 As used in this paragraph, "CPT code" means the medical
1308	1308	17 billing code set contained in the most recent version of the
1309	1309	18 Current Procedural Terminology code book published by the
1310	1310	19 American Medical Association.
1311	1311	20 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1312	1312	21 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1313	1313	22 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1314	1314	23 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1315	1315	24 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1316	1316	25 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1317	1317	26 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1318	1318
1319	1319
1320	1320
1321	1321
1322	1322
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1324	1324
1325	1325
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1328	1328
1329	1329
1330	1330
1331	1331
1332	1332
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