Illinois 2023-2024 Regular Session

Illinois House Bill HB4901 Compare Versions

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

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1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4901 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in effect on December 31, 2024. Provides that the rates paid for nitrous oxide sedation shall not be impacted by the amendatory Act and shall remain the same as the rates in effect on December 31, 2024. Effective January 1, 2025. LRB103 36276 KTG 66373 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4901 Introduced , by Rep. Natalie A. Manley 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 on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in effect on December 31, 2024. Provides that the rates paid for nitrous oxide sedation shall not be impacted by the amendatory Act and shall remain the same as the rates in effect on December 31, 2024. Effective January 1, 2025. LRB103 36276 KTG 66373 b LRB103 36276 KTG 66373 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4901 Introduced , by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 305 ILCS 5/5-5
4	4	305 ILCS 5/5-5
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in effect on December 31, 2024. Provides that the rates paid for nitrous oxide sedation shall not be impacted by the amendatory Act and shall remain the same as the rates in effect on December 31, 2024. Effective January 1, 2025.
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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 HB4901 Introduced , by Rep. Natalie A. Manley 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 on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in effect on December 31, 2024. Provides that the rates paid for nitrous oxide sedation shall not be impacted by the amendatory Act and shall remain the same as the rates in effect on December 31, 2024. Effective January 1, 2025.
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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 On and after January 1, 2025, the rates paid for sedation
234	234	23 evaluation and the provision of deep sedation and intravenous
235	235	24 sedation for the purpose of dental services shall be increased
236	236	25 by 33% above the rates in effect on December 31, 2024. The
237	237	26 rates paid for nitrous oxide sedation shall not be impacted by
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248	248	1 this paragraph and shall remain the same as the rates in effect
249	249	2 on December 31, 2024.
250	250	3 Notwithstanding any other provision of this Code and
251	251	4 subject to federal approval, the Department may adopt rules to
252	252	5 allow a dentist who is volunteering his or her service at no
253	253	6 cost to render dental services through an enrolled
254	254	7 not-for-profit health clinic without the dentist personally
255	255	8 enrolling as a participating provider in the medical
256	256	9 assistance program. A not-for-profit health clinic shall
257	257	10 include a public health clinic or Federally Qualified Health
258	258	11 Center or other enrolled provider, as determined by the
259	259	12 Department, through which dental services covered under this
260	260	13 Section are performed. The Department shall establish a
261	261	14 process for payment of claims for reimbursement for covered
262	262	15 dental services rendered under this provision.
263	263	16 On and after January 1, 2022, the Department of Healthcare
264	264	17 and Family Services shall administer and regulate a
265	265	18 school-based dental program that allows for the out-of-office
266	266	19 delivery of preventative dental services in a school setting
267	267	20 to children under 19 years of age. The Department shall
268	268	21 establish, by rule, guidelines for participation by providers
269	269	22 and set requirements for follow-up referral care based on the
270	270	23 requirements established in the Dental Office Reference Manual
271	271	24 published by the Department that establishes the requirements
272	272	25 for dentists participating in the All Kids Dental School
273	273	26 Program. Every effort shall be made by the Department when
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284	284	1 developing the program requirements to consider the different
285	285	2 geographic differences of both urban and rural areas of the
286	286	3 State for initial treatment and necessary follow-up care. No
287	287	4 provider shall be charged a fee by any unit of local government
288	288	5 to participate in the school-based dental program administered
289	289	6 by the Department. Nothing in this paragraph shall be
290	290	7 construed to limit or preempt a home rule unit's or school
291	291	8 district's authority to establish, change, or administer a
292	292	9 school-based dental program in addition to, or independent of,
293	293	10 the school-based dental program administered by the
294	294	11 Department.
295	295	12 The Illinois Department, by rule, may distinguish and
296	296	13 classify the medical services to be provided only in
297	297	14 accordance with the classes of persons designated in Section
298	298	15 5-2.
299	299	16 The Department of Healthcare and Family Services must
300	300	17 provide coverage and reimbursement for amino acid-based
301	301	18 elemental formulas, regardless of delivery method, for the
302	302	19 diagnosis and treatment of (i) eosinophilic disorders and (ii)
303	303	20 short bowel syndrome when the prescribing physician has issued
304	304	21 a written order stating that the amino acid-based elemental
305	305	22 formula is medically necessary.
306	306	23 The Illinois Department shall authorize the provision of,
307	307	24 and shall authorize payment for, screening by low-dose
308	308	25 mammography for the presence of occult breast cancer for
309	309	26 individuals 35 years of age or older who are eligible for
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320	320	1 medical assistance under this Article, as follows:
321	321	2 (A) A baseline mammogram for individuals 35 to 39
322	322	3 years of age.
323	323	4 (B) An annual mammogram for individuals 40 years of
324	324	5 age or older.
325	325	6 (C) A mammogram at the age and intervals considered
326	326	7 medically necessary by the individual's health care
327	327	8 provider for individuals under 40 years of age and having
328	328	9 a family history of breast cancer, prior personal history
329	329	10 of breast cancer, positive genetic testing, or other risk
330	330	11 factors.
331	331	12 (D) A comprehensive ultrasound screening and MRI of an
332	332	13 entire breast or breasts if a mammogram demonstrates
333	333	14 heterogeneous or dense breast tissue or when medically
334	334	15 necessary as determined by a physician licensed to
335	335	16 practice medicine in all of its branches.
336	336	17 (E) A screening MRI when medically necessary, as
337	337	18 determined by a physician licensed to practice medicine in
338	338	19 all of its branches.
339	339	20 (F) A diagnostic mammogram when medically necessary,
340	340	21 as determined by a physician licensed to practice medicine
341	341	22 in all its branches, advanced practice registered nurse,
342	342	23 or physician assistant.
343	343	24 The Department shall not impose a deductible, coinsurance,
344	344	25 copayment, or any other cost-sharing requirement on the
345	345	26 coverage provided under this paragraph; except that this
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356	356	1 sentence does not apply to coverage of diagnostic mammograms
357	357	2 to the extent such coverage would disqualify a high-deductible
358	358	3 health plan from eligibility for a health savings account
359	359	4 pursuant to Section 223 of the Internal Revenue Code (26
360	360	5 U.S.C. 223).
361	361	6 All screenings shall include a physical breast exam,
362	362	7 instruction on self-examination and information regarding the
363	363	8 frequency of self-examination and its value as a preventative
364	364	9 tool.
365	365	10 For purposes of this Section:
366	366	11 "Diagnostic mammogram" means a mammogram obtained using
367	367	12 diagnostic mammography.
368	368	13 "Diagnostic mammography" means a method of screening that
369	369	14 is designed to evaluate an abnormality in a breast, including
370	370	15 an abnormality seen or suspected on a screening mammogram or a
371	371	16 subjective or objective abnormality otherwise detected in the
372	372	17 breast.
373	373	18 "Low-dose mammography" means the x-ray examination of the
374	374	19 breast using equipment dedicated specifically for mammography,
375	375	20 including the x-ray tube, filter, compression device, and
376	376	21 image receptor, with an average radiation exposure delivery of
377	377	22 less than one rad per breast for 2 views of an average size
378	378	23 breast. The term also includes digital mammography and
379	379	24 includes breast tomosynthesis.
380	380	25 "Breast tomosynthesis" means a radiologic procedure that
381	381	26 involves the acquisition of projection images over the
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392	392	1 stationary breast to produce cross-sectional digital
393	393	2 three-dimensional images of the breast.
394	394	3 If, at any time, the Secretary of the United States
395	395	4 Department of Health and Human Services, or its successor
396	396	5 agency, promulgates rules or regulations to be published in
397	397	6 the Federal Register or publishes a comment in the Federal
398	398	7 Register or issues an opinion, guidance, or other action that
399	399	8 would require the State, pursuant to any provision of the
400	400	9 Patient Protection and Affordable Care Act (Public Law
401	401	10 111-148), including, but not limited to, 42 U.S.C.
402	402	11 18031(d)(3)(B) or any successor provision, to defray the cost
403	403	12 of any coverage for breast tomosynthesis outlined in this
404	404	13 paragraph, then the requirement that an insurer cover breast
405	405	14 tomosynthesis is inoperative other than any such coverage
406	406	15 authorized under Section 1902 of the Social Security Act, 42
407	407	16 U.S.C. 1396a, and the State shall not assume any obligation
408	408	17 for the cost of coverage for breast tomosynthesis set forth in
409	409	18 this paragraph.
410	410	19 On and after January 1, 2016, the Department shall ensure
411	411	20 that all networks of care for adult clients of the Department
412	412	21 include access to at least one breast imaging Center of
413	413	22 Imaging Excellence as certified by the American College of
414	414	23 Radiology.
415	415	24 On and after January 1, 2012, providers participating in a
416	416	25 quality improvement program approved by the Department shall
417	417	26 be reimbursed for screening and diagnostic mammography at the
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428	428	1 same rate as the Medicare program's rates, including the
429	429	2 increased reimbursement for digital mammography and, after
430	430	3 January 1, 2023 (the effective date of Public Act 102-1018),
431	431	4 breast tomosynthesis.
432	432	5 The Department shall convene an expert panel including
433	433	6 representatives of hospitals, free-standing mammography
434	434	7 facilities, and doctors, including radiologists, to establish
435	435	8 quality standards for mammography.
436	436	9 On and after January 1, 2017, providers participating in a
437	437	10 breast cancer treatment quality improvement program approved
438	438	11 by the Department shall be reimbursed for breast cancer
439	439	12 treatment at a rate that is no lower than 95% of the Medicare
440	440	13 program's rates for the data elements included in the breast
441	441	14 cancer treatment quality program.
442	442	15 The Department shall convene an expert panel, including
443	443	16 representatives of hospitals, free-standing breast cancer
444	444	17 treatment centers, breast cancer quality organizations, and
445	445	18 doctors, including breast surgeons, reconstructive breast
446	446	19 surgeons, oncologists, and primary care providers to establish
447	447	20 quality standards for breast cancer treatment.
448	448	21 Subject to federal approval, the Department shall
449	449	22 establish a rate methodology for mammography at federally
450	450	23 qualified health centers and other encounter-rate clinics.
451	451	24 These clinics or centers may also collaborate with other
452	452	25 hospital-based mammography facilities. By January 1, 2016, the
453	453	26 Department shall report to the General Assembly on the status
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464	464	1 of the provision set forth in this paragraph.
465	465	2 The Department shall establish a methodology to remind
466	466	3 individuals who are age-appropriate for screening mammography,
467	467	4 but who have not received a mammogram within the previous 18
468	468	5 months, of the importance and benefit of screening
469	469	6 mammography. The Department shall work with experts in breast
470	470	7 cancer outreach and patient navigation to optimize these
471	471	8 reminders and shall establish a methodology for evaluating
472	472	9 their effectiveness and modifying the methodology based on the
473	473	10 evaluation.
474	474	11 The Department shall establish a performance goal for
475	475	12 primary care providers with respect to their female patients
476	476	13 over age 40 receiving an annual mammogram. This performance
477	477	14 goal shall be used to provide additional reimbursement in the
478	478	15 form of a quality performance bonus to primary care providers
479	479	16 who meet that goal.
480	480	17 The Department shall devise a means of case-managing or
481	481	18 patient navigation for beneficiaries diagnosed with breast
482	482	19 cancer. This program shall initially operate as a pilot
483	483	20 program in areas of the State with the highest incidence of
484	484	21 mortality related to breast cancer. At least one pilot program
485	485	22 site shall be in the metropolitan Chicago area and at least one
486	486	23 site shall be outside the metropolitan Chicago area. On or
487	487	24 after July 1, 2016, the pilot program shall be expanded to
488	488	25 include one site in western Illinois, one site in southern
489	489	26 Illinois, one site in central Illinois, and 4 sites within
490	490
491	491
492	492
493	493
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500	500	1 metropolitan Chicago. An evaluation of the pilot program shall
501	501	2 be carried out measuring health outcomes and cost of care for
502	502	3 those served by the pilot program compared to similarly
503	503	4 situated patients who are not served by the pilot program.
504	504	5 The Department shall require all networks of care to
505	505	6 develop a means either internally or by contract with experts
506	506	7 in navigation and community outreach to navigate cancer
507	507	8 patients to comprehensive care in a timely fashion. The
508	508	9 Department shall require all networks of care to include
509	509	10 access for patients diagnosed with cancer to at least one
510	510	11 academic commission on cancer-accredited cancer program as an
511	511	12 in-network covered benefit.
512	512	13 The Department shall provide coverage and reimbursement
513	513	14 for a human papillomavirus (HPV) vaccine that is approved for
514	514	15 marketing by the federal Food and Drug Administration for all
515	515	16 persons between the ages of 9 and 45. Subject to federal
516	516	17 approval, the Department shall provide coverage and
517	517	18 reimbursement for a human papillomavirus (HPV) vaccine for
518	518	19 persons of the age of 46 and above who have been diagnosed with
519	519	20 cervical dysplasia with a high risk of recurrence or
520	520	21 progression. The Department shall disallow any
521	521	22 preauthorization requirements for the administration of the
522	522	23 human papillomavirus (HPV) vaccine.
523	523	24 On or after July 1, 2022, individuals who are otherwise
524	524	25 eligible for medical assistance under this Article shall
525	525	26 receive coverage for perinatal depression screenings for the
526	526
527	527
528	528
529	529
530	530
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532	532
533	533
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536	536	1 12-month period beginning on the last day of their pregnancy.
537	537	2 Medical assistance coverage under this paragraph shall be
538	538	3 conditioned on the use of a screening instrument approved by
539	539	4 the Department.
540	540	5 Any medical or health care provider shall immediately
541	541	6 recommend, to any pregnant individual who is being provided
542	542	7 prenatal services and is suspected of having a substance use
543	543	8 disorder as defined in the Substance Use Disorder Act,
544	544	9 referral to a local substance use disorder treatment program
545	545	10 licensed by the Department of Human Services or to a licensed
546	546	11 hospital which provides substance abuse treatment services.
547	547	12 The Department of Healthcare and Family Services shall assure
548	548	13 coverage for the cost of treatment of the drug abuse or
549	549	14 addiction for pregnant recipients in accordance with the
550	550	15 Illinois Medicaid Program in conjunction with the Department
551	551	16 of Human Services.
552	552	17 All medical providers providing medical assistance to
553	553	18 pregnant individuals under this Code shall receive information
554	554	19 from the Department on the availability of services under any
555	555	20 program providing case management services for addicted
556	556	21 individuals, including information on appropriate referrals
557	557	22 for other social services that may be needed by addicted
558	558	23 individuals in addition to treatment for addiction.
559	559	24 The Illinois Department, in cooperation with the
560	560	25 Departments of Human Services (as successor to the Department
561	561	26 of Alcoholism and Substance Abuse) and Public Health, through
562	562
563	563
564	564
565	565
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568	568
569	569
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572	572	1 a public awareness campaign, may provide information
573	573	2 concerning treatment for alcoholism and drug abuse and
574	574	3 addiction, prenatal health care, and other pertinent programs
575	575	4 directed at reducing the number of drug-affected infants born
576	576	5 to recipients of medical assistance.
577	577	6 Neither the Department of Healthcare and Family Services
578	578	7 nor the Department of Human Services shall sanction the
579	579	8 recipient solely on the basis of the recipient's substance
580	580	9 abuse.
581	581	10 The Illinois Department shall establish such regulations
582	582	11 governing the dispensing of health services under this Article
583	583	12 as it shall deem appropriate. The Department should seek the
584	584	13 advice of formal professional advisory committees appointed by
585	585	14 the Director of the Illinois Department for the purpose of
586	586	15 providing regular advice on policy and administrative matters,
587	587	16 information dissemination and educational activities for
588	588	17 medical and health care providers, and consistency in
589	589	18 procedures to the Illinois Department.
590	590	19 The Illinois Department may develop and contract with
591	591	20 Partnerships of medical providers to arrange medical services
592	592	21 for persons eligible under Section 5-2 of this Code.
593	593	22 Implementation of this Section may be by demonstration
594	594	23 projects in certain geographic areas. The Partnership shall be
595	595	24 represented by a sponsor organization. The Department, by
596	596	25 rule, shall develop qualifications for sponsors of
597	597	26 Partnerships. Nothing in this Section shall be construed to
598	598
599	599
600	600
601	601
602	602
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608	608	1 require that the sponsor organization be a medical
609	609	2 organization.
610	610	3 The sponsor must negotiate formal written contracts with
611	611	4 medical providers for physician services, inpatient and
612	612	5 outpatient hospital care, home health services, treatment for
613	613	6 alcoholism and substance abuse, and other services determined
614	614	7 necessary by the Illinois Department by rule for delivery by
615	615	8 Partnerships. Physician services must include prenatal and
616	616	9 obstetrical care. The Illinois Department shall reimburse
617	617	10 medical services delivered by Partnership providers to clients
618	618	11 in target areas according to provisions of this Article and
619	619	12 the Illinois Health Finance Reform Act, except that:
620	620	13 (1) Physicians participating in a Partnership and
621	621	14 providing certain services, which shall be determined by
622	622	15 the Illinois Department, to persons in areas covered by
623	623	16 the Partnership may receive an additional surcharge for
624	624	17 such services.
625	625	18 (2) The Department may elect to consider and negotiate
626	626	19 financial incentives to encourage the development of
627	627	20 Partnerships and the efficient delivery of medical care.
628	628	21 (3) Persons receiving medical services through
629	629	22 Partnerships may receive medical and case management
630	630	23 services above the level usually offered through the
631	631	24 medical assistance program.
632	632	25 Medical providers shall be required to meet certain
633	633	26 qualifications to participate in Partnerships to ensure the
634	634
635	635
636	636
637	637
638	638
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640	640
641	641
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643	643	HB4901 - 18 - LRB103 36276 KTG 66373 b
644	644	1 delivery of high quality medical services. These
645	645	2 qualifications shall be determined by rule of the Illinois
646	646	3 Department and may be higher than qualifications for
647	647	4 participation in the medical assistance program. Partnership
648	648	5 sponsors may prescribe reasonable additional qualifications
649	649	6 for participation by medical providers, only with the prior
650	650	7 written approval of the Illinois Department.
651	651	8 Nothing in this Section shall limit the free choice of
652	652	9 practitioners, hospitals, and other providers of medical
653	653	10 services by clients. In order to ensure patient freedom of
654	654	11 choice, the Illinois Department shall immediately promulgate
655	655	12 all rules and take all other necessary actions so that
656	656	13 provided services may be accessed from therapeutically
657	657	14 certified optometrists to the full extent of the Illinois
658	658	15 Optometric Practice Act of 1987 without discriminating between
659	659	16 service providers.
660	660	17 The Department shall apply for a waiver from the United
661	661	18 States Health Care Financing Administration to allow for the
662	662	19 implementation of Partnerships under this Section.
663	663	20 The Illinois Department shall require health care
664	664	21 providers to maintain records that document the medical care
665	665	22 and services provided to recipients of Medical Assistance
666	666	23 under this Article. Such records must be retained for a period
667	667	24 of not less than 6 years from the date of service or as
668	668	25 provided by applicable State law, whichever period is longer,
669	669	26 except that if an audit is initiated within the required
670	670
671	671
672	672
673	673
674	674
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676	676
677	677
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680	680	1 retention period then the records must be retained until the
681	681	2 audit is completed and every exception is resolved. The
682	682	3 Illinois Department shall require health care providers to
683	683	4 make available, when authorized by the patient, in writing,
684	684	5 the medical records in a timely fashion to other health care
685	685	6 providers who are treating or serving persons eligible for
686	686	7 Medical Assistance under this Article. All dispensers of
687	687	8 medical services shall be required to maintain and retain
688	688	9 business and professional records sufficient to fully and
689	689	10 accurately document the nature, scope, details and receipt of
690	690	11 the health care provided to persons eligible for medical
691	691	12 assistance under this Code, in accordance with regulations
692	692	13 promulgated by the Illinois Department. The rules and
693	693	14 regulations shall require that proof of the receipt of
694	694	15 prescription drugs, dentures, prosthetic devices and
695	695	16 eyeglasses by eligible persons under this Section accompany
696	696	17 each claim for reimbursement submitted by the dispenser of
697	697	18 such medical services. No such claims for reimbursement shall
698	698	19 be approved for payment by the Illinois Department without
699	699	20 such proof of receipt, unless the Illinois Department shall
700	700	21 have put into effect and shall be operating a system of
701	701	22 post-payment audit and review which shall, on a sampling
702	702	23 basis, be deemed adequate by the Illinois Department to assure
703	703	24 that such drugs, dentures, prosthetic devices and eyeglasses
704	704	25 for which payment is being made are actually being received by
705	705	26 eligible recipients. Within 90 days after September 16, 1984
706	706
707	707
708	708
709	709
710	710
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712	712
713	713
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716	716	1 (the effective date of Public Act 83-1439), the Illinois
717	717	2 Department shall establish a current list of acquisition costs
718	718	3 for all prosthetic devices and any other items recognized as
719	719	4 medical equipment and supplies reimbursable under this Article
720	720	5 and shall update such list on a quarterly basis, except that
721	721	6 the acquisition costs of all prescription drugs shall be
722	722	7 updated no less frequently than every 30 days as required by
723	723	8 Section 5-5.12.
724	724	9 Notwithstanding any other law to the contrary, the
725	725	10 Illinois Department shall, within 365 days after July 22, 2013
726	726	11 (the effective date of Public Act 98-104), establish
727	727	12 procedures to permit skilled care facilities licensed under
728	728	13 the Nursing Home Care Act to submit monthly billing claims for
729	729	14 reimbursement purposes. Following development of these
730	730	15 procedures, the Department shall, by July 1, 2016, test the
731	731	16 viability of the new system and implement any necessary
732	732	17 operational or structural changes to its information
733	733	18 technology platforms in order to allow for the direct
734	734	19 acceptance and payment of nursing home claims.
735	735	20 Notwithstanding any other law to the contrary, the
736	736	21 Illinois Department shall, within 365 days after August 15,
737	737	22 2014 (the effective date of Public Act 98-963), establish
738	738	23 procedures to permit ID/DD facilities licensed under the ID/DD
739	739	24 Community Care Act and MC/DD facilities licensed under the
740	740	25 MC/DD Act to submit monthly billing claims for reimbursement
741	741	26 purposes. Following development of these procedures, the
742	742
743	743
744	744
745	745
746	746
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748	748
749	749
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752	752	1 Department shall have an additional 365 days to test the
753	753	2 viability of the new system and to ensure that any necessary
754	754	3 operational or structural changes to its information
755	755	4 technology platforms are implemented.
756	756	5 The Illinois Department shall require all dispensers of
757	757	6 medical services, other than an individual practitioner or
758	758	7 group of practitioners, desiring to participate in the Medical
759	759	8 Assistance program established under this Article to disclose
760	760	9 all financial, beneficial, ownership, equity, surety or other
761	761	10 interests in any and all firms, corporations, partnerships,
762	762	11 associations, business enterprises, joint ventures, agencies,
763	763	12 institutions or other legal entities providing any form of
764	764	13 health care services in this State under this Article.
765	765	14 The Illinois Department may require that all dispensers of
766	766	15 medical services desiring to participate in the medical
767	767	16 assistance program established under this Article disclose,
768	768	17 under such terms and conditions as the Illinois Department may
769	769	18 by rule establish, all inquiries from clients and attorneys
770	770	19 regarding medical bills paid by the Illinois Department, which
771	771	20 inquiries could indicate potential existence of claims or
772	772	21 liens for the Illinois Department.
773	773	22 Enrollment of a vendor shall be subject to a provisional
774	774	23 period and shall be conditional for one year. During the
775	775	24 period of conditional enrollment, the Department may terminate
776	776	25 the vendor's eligibility to participate in, or may disenroll
777	777	26 the vendor from, the medical assistance program without cause.
778	778
779	779
780	780
781	781
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784	784
785	785
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788	788	1 Unless otherwise specified, such termination of eligibility or
789	789	2 disenrollment is not subject to the Department's hearing
790	790	3 process. However, a disenrolled vendor may reapply without
791	791	4 penalty.
792	792	5 The Department has the discretion to limit the conditional
793	793	6 enrollment period for vendors based upon the category of risk
794	794	7 of the vendor.
795	795	8 Prior to enrollment and during the conditional enrollment
796	796	9 period in the medical assistance program, all vendors shall be
797	797	10 subject to enhanced oversight, screening, and review based on
798	798	11 the risk of fraud, waste, and abuse that is posed by the
799	799	12 category of risk of the vendor. The Illinois Department shall
800	800	13 establish the procedures for oversight, screening, and review,
801	801	14 which may include, but need not be limited to: criminal and
802	802	15 financial background checks; fingerprinting; license,
803	803	16 certification, and authorization verifications; unscheduled or
804	804	17 unannounced site visits; database checks; prepayment audit
805	805	18 reviews; audits; payment caps; payment suspensions; and other
806	806	19 screening as required by federal or State law.
807	807	20 The Department shall define or specify the following: (i)
808	808	21 by provider notice, the "category of risk of the vendor" for
809	809	22 each type of vendor, which shall take into account the level of
810	810	23 screening applicable to a particular category of vendor under
811	811	24 federal law and regulations; (ii) by rule or provider notice,
812	812	25 the maximum length of the conditional enrollment period for
813	813	26 each category of risk of the vendor; and (iii) by rule, the
814	814
815	815
816	816
817	817
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820	820
821	821
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824	824	1 hearing rights, if any, afforded to a vendor in each category
825	825	2 of risk of the vendor that is terminated or disenrolled during
826	826	3 the conditional enrollment period.
827	827	4 To be eligible for payment consideration, a vendor's
828	828	5 payment claim or bill, either as an initial claim or as a
829	829	6 resubmitted claim following prior rejection, must be received
830	830	7 by the Illinois Department, or its fiscal intermediary, no
831	831	8 later than 180 days after the latest date on the claim on which
832	832	9 medical goods or services were provided, with the following
833	833	10 exceptions:
834	834	11 (1) In the case of a provider whose enrollment is in
835	835	12 process by the Illinois Department, the 180-day period
836	836	13 shall not begin until the date on the written notice from
837	837	14 the Illinois Department that the provider enrollment is
838	838	15 complete.
839	839	16 (2) In the case of errors attributable to the Illinois
840	840	17 Department or any of its claims processing intermediaries
841	841	18 which result in an inability to receive, process, or
842	842	19 adjudicate a claim, the 180-day period shall not begin
843	843	20 until the provider has been notified of the error.
844	844	21 (3) In the case of a provider for whom the Illinois
845	845	22 Department initiates the monthly billing process.
846	846	23 (4) In the case of a provider operated by a unit of
847	847	24 local government with a population exceeding 3,000,000
848	848	25 when local government funds finance federal participation
849	849	26 for claims payments.
850	850
851	851
852	852
853	853
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856	856
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860	860	1 For claims for services rendered during a period for which
861	861	2 a recipient received retroactive eligibility, claims must be
862	862	3 filed within 180 days after the Department determines the
863	863	4 applicant is eligible. For claims for which the Illinois
864	864	5 Department is not the primary payer, claims must be submitted
865	865	6 to the Illinois Department within 180 days after the final
866	866	7 adjudication by the primary payer.
867	867	8 In the case of long term care facilities, within 120
868	868	9 calendar days of receipt by the facility of required
869	869	10 prescreening information, new admissions with associated
870	870	11 admission documents shall be submitted through the Medical
871	871	12 Electronic Data Interchange (MEDI) or the Recipient
872	872	13 Eligibility Verification (REV) System or shall be submitted
873	873	14 directly to the Department of Human Services using required
874	874	15 admission forms. Effective September 1, 2014, admission
875	875	16 documents, including all prescreening information, must be
876	876	17 submitted through MEDI or REV. Confirmation numbers assigned
877	877	18 to an accepted transaction shall be retained by a facility to
878	878	19 verify timely submittal. Once an admission transaction has
879	879	20 been completed, all resubmitted claims following prior
880	880	21 rejection are subject to receipt no later than 180 days after
881	881	22 the admission transaction has been completed.
882	882	23 Claims that are not submitted and received in compliance
883	883	24 with the foregoing requirements shall not be eligible for
884	884	25 payment under the medical assistance program, and the State
885	885	26 shall have no liability for payment of those claims.
886	886
887	887
888	888
889	889
890	890
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892	892
893	893
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896	896	1 To the extent consistent with applicable information and
897	897	2 privacy, security, and disclosure laws, State and federal
898	898	3 agencies and departments shall provide the Illinois Department
899	899	4 access to confidential and other information and data
900	900	5 necessary to perform eligibility and payment verifications and
901	901	6 other Illinois Department functions. This includes, but is not
902	902	7 limited to: information pertaining to licensure;
903	903	8 certification; earnings; immigration status; citizenship; wage
904	904	9 reporting; unearned and earned income; pension income;
905	905	10 employment; supplemental security income; social security
906	906	11 numbers; National Provider Identifier (NPI) numbers; the
907	907	12 National Practitioner Data Bank (NPDB); program and agency
908	908	13 exclusions; taxpayer identification numbers; tax delinquency;
909	909	14 corporate information; and death records.
910	910	15 The Illinois Department shall enter into agreements with
911	911	16 State agencies and departments, and is authorized to enter
912	912	17 into agreements with federal agencies and departments, under
913	913	18 which such agencies and departments shall share data necessary
914	914	19 for medical assistance program integrity functions and
915	915	20 oversight. The Illinois Department shall develop, in
916	916	21 cooperation with other State departments and agencies, and in
917	917	22 compliance with applicable federal laws and regulations,
918	918	23 appropriate and effective methods to share such data. At a
919	919	24 minimum, and to the extent necessary to provide data sharing,
920	920	25 the Illinois Department shall enter into agreements with State
921	921	26 agencies and departments, and is authorized to enter into
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 agreements with federal agencies and departments, including,
933	933	2 but not limited to: the Secretary of State; the Department of
934	934	3 Revenue; the Department of Public Health; the Department of
935	935	4 Human Services; and the Department of Financial and
936	936	5 Professional Regulation.
937	937	6 Beginning in fiscal year 2013, the Illinois Department
938	938	7 shall set forth a request for information to identify the
939	939	8 benefits of a pre-payment, post-adjudication, and post-edit
940	940	9 claims system with the goals of streamlining claims processing
941	941	10 and provider reimbursement, reducing the number of pending or
942	942	11 rejected claims, and helping to ensure a more transparent
943	943	12 adjudication process through the utilization of: (i) provider
944	944	13 data verification and provider screening technology; and (ii)
945	945	14 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
946	946	15 post-adjudicated predictive modeling with an integrated case
947	947	16 management system with link analysis. Such a request for
948	948	17 information shall not be considered as a request for proposal
949	949	18 or as an obligation on the part of the Illinois Department to
950	950	19 take any action or acquire any products or services.
951	951	20 The Illinois Department shall establish policies,
952	952	21 procedures, standards and criteria by rule for the
953	953	22 acquisition, repair and replacement of orthotic and prosthetic
954	954	23 devices and durable medical equipment. Such rules shall
955	955	24 provide, but not be limited to, the following services: (1)
956	956	25 immediate repair or replacement of such devices by recipients;
957	957	26 and (2) rental, lease, purchase or lease-purchase of durable
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 medical equipment in a cost-effective manner, taking into
969	969	2 consideration the recipient's medical prognosis, the extent of
970	970	3 the recipient's needs, and the requirements and costs for
971	971	4 maintaining such equipment. Subject to prior approval, such
972	972	5 rules shall enable a recipient to temporarily acquire and use
973	973	6 alternative or substitute devices or equipment pending repairs
974	974	7 or replacements of any device or equipment previously
975	975	8 authorized for such recipient by the Department.
976	976	9 Notwithstanding any provision of Section 5-5f to the contrary,
977	977	10 the Department may, by rule, exempt certain replacement
978	978	11 wheelchair parts from prior approval and, for wheelchairs,
979	979	12 wheelchair parts, wheelchair accessories, and related seating
980	980	13 and positioning items, determine the wholesale price by
981	981	14 methods other than actual acquisition costs.
982	982	15 The Department shall require, by rule, all providers of
983	983	16 durable medical equipment to be accredited by an accreditation
984	984	17 organization approved by the federal Centers for Medicare and
985	985	18 Medicaid Services and recognized by the Department in order to
986	986	19 bill the Department for providing durable medical equipment to
987	987	20 recipients. No later than 15 months after the effective date
988	988	21 of the rule adopted pursuant to this paragraph, all providers
989	989	22 must meet the accreditation requirement.
990	990	23 In order to promote environmental responsibility, meet the
991	991	24 needs of recipients and enrollees, and achieve significant
992	992	25 cost savings, the Department, or a managed care organization
993	993	26 under contract with the Department, may provide recipients or
994	994
995	995
996	996
997	997
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1001	1001
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1004	1004	1 managed care enrollees who have a prescription or Certificate
1005	1005	2 of Medical Necessity access to refurbished durable medical
1006	1006	3 equipment under this Section (excluding prosthetic and
1007	1007	4 orthotic devices as defined in the Orthotics, Prosthetics, and
1008	1008	5 Pedorthics Practice Act and complex rehabilitation technology
1009	1009	6 products and associated services) through the State's
1010	1010	7 assistive technology program's reutilization program, using
1011	1011	8 staff with the Assistive Technology Professional (ATP)
1012	1012	9 Certification if the refurbished durable medical equipment:
1013	1013	10 (i) is available; (ii) is less expensive, including shipping
1014	1014	11 costs, than new durable medical equipment of the same type;
1015	1015	12 (iii) is able to withstand at least 3 years of use; (iv) is
1016	1016	13 cleaned, disinfected, sterilized, and safe in accordance with
1017	1017	14 federal Food and Drug Administration regulations and guidance
1018	1018	15 governing the reprocessing of medical devices in health care
1019	1019	16 settings; and (v) equally meets the needs of the recipient or
1020	1020	17 enrollee. The reutilization program shall confirm that the
1021	1021	18 recipient or enrollee is not already in receipt of the same or
1022	1022	19 similar equipment from another service provider, and that the
1023	1023	20 refurbished durable medical equipment equally meets the needs
1024	1024	21 of the recipient or enrollee. Nothing in this paragraph shall
1025	1025	22 be construed to limit recipient or enrollee choice to obtain
1026	1026	23 new durable medical equipment or place any additional prior
1027	1027	24 authorization conditions on enrollees of managed care
1028	1028	25 organizations.
1029	1029	26 The Department shall execute, relative to the nursing home
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
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1036	1036
1037	1037
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1039	1039	HB4901 - 29 - LRB103 36276 KTG 66373 b
1040	1040	1 prescreening project, written inter-agency agreements with the
1041	1041	2 Department of Human Services and the Department on Aging, to
1042	1042	3 effect the following: (i) intake procedures and common
1043	1043	4 eligibility criteria for those persons who are receiving
1044	1044	5 non-institutional services; and (ii) the establishment and
1045	1045	6 development of non-institutional services in areas of the
1046	1046	7 State where they are not currently available or are
1047	1047	8 undeveloped; and (iii) notwithstanding any other provision of
1048	1048	9 law, subject to federal approval, on and after July 1, 2012, an
1049	1049	10 increase in the determination of need (DON) scores from 29 to
1050	1050	11 37 for applicants for institutional and home and
1051	1051	12 community-based long term care; if and only if federal
1052	1052	13 approval is not granted, the Department may, in conjunction
1053	1053	14 with other affected agencies, implement utilization controls
1054	1054	15 or changes in benefit packages to effectuate a similar savings
1055	1055	16 amount for this population; and (iv) no later than July 1,
1056	1056	17 2013, minimum level of care eligibility criteria for
1057	1057	18 institutional and home and community-based long term care; and
1058	1058	19 (v) no later than October 1, 2013, establish procedures to
1059	1059	20 permit long term care providers access to eligibility scores
1060	1060	21 for individuals with an admission date who are seeking or
1061	1061	22 receiving services from the long term care provider. In order
1062	1062	23 to select the minimum level of care eligibility criteria, the
1063	1063	24 Governor shall establish a workgroup that includes affected
1064	1064	25 agency representatives and stakeholders representing the
1065	1065	26 institutional and home and community-based long term care
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB4901 - 29 - LRB103 36276 KTG 66373 b
1072	1072
1073	1073
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1075	1075	HB4901 - 30 - LRB103 36276 KTG 66373 b
1076	1076	1 interests. This Section shall not restrict the Department from
1077	1077	2 implementing lower level of care eligibility criteria for
1078	1078	3 community-based services in circumstances where federal
1079	1079	4 approval has been granted.
1080	1080	5 The Illinois Department shall develop and operate, in
1081	1081	6 cooperation with other State Departments and agencies and in
1082	1082	7 compliance with applicable federal laws and regulations,
1083	1083	8 appropriate and effective systems of health care evaluation
1084	1084	9 and programs for monitoring of utilization of health care
1085	1085	10 services and facilities, as it affects persons eligible for
1086	1086	11 medical assistance under this Code.
1087	1087	12 The Illinois Department shall report annually to the
1088	1088	13 General Assembly, no later than the second Friday in April of
1089	1089	14 1979 and each year thereafter, in regard to:
1090	1090	15 (a) actual statistics and trends in utilization of
1091	1091	16 medical services by public aid recipients;
1092	1092	17 (b) actual statistics and trends in the provision of
1093	1093	18 the various medical services by medical vendors;
1094	1094	19 (c) current rate structures and proposed changes in
1095	1095	20 those rate structures for the various medical vendors; and
1096	1096	21 (d) efforts at utilization review and control by the
1097	1097	22 Illinois Department.
1098	1098	23 The period covered by each report shall be the 3 years
1099	1099	24 ending on the June 30 prior to the report. The report shall
1100	1100	25 include suggested legislation for consideration by the General
1101	1101	26 Assembly. The requirement for reporting to the General
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
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1108	1108
1109	1109
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1111	1111	HB4901 - 31 - LRB103 36276 KTG 66373 b
1112	1112	1 Assembly shall be satisfied by filing copies of the report as
1113	1113	2 required by Section 3.1 of the General Assembly Organization
1114	1114	3 Act, and filing such additional copies with the State
1115	1115	4 Government Report Distribution Center for the General Assembly
1116	1116	5 as is required under paragraph (t) of Section 7 of the State
1117	1117	6 Library Act.
1118	1118	7 Rulemaking authority to implement Public Act 95-1045, if
1119	1119	8 any, is conditioned on the rules being adopted in accordance
1120	1120	9 with all provisions of the Illinois Administrative Procedure
1121	1121	10 Act and all rules and procedures of the Joint Committee on
1122	1122	11 Administrative Rules; any purported rule not so adopted, for
1123	1123	12 whatever reason, is unauthorized.
1124	1124	13 On and after July 1, 2012, the Department shall reduce any
1125	1125	14 rate of reimbursement for services or other payments or alter
1126	1126	15 any methodologies authorized by this Code to reduce any rate
1127	1127	16 of reimbursement for services or other payments in accordance
1128	1128	17 with Section 5-5e.
1129	1129	18 Because kidney transplantation can be an appropriate,
1130	1130	19 cost-effective alternative to renal dialysis when medically
1131	1131	20 necessary and notwithstanding the provisions of Section 1-11
1132	1132	21 of this Code, beginning October 1, 2014, the Department shall
1133	1133	22 cover kidney transplantation for noncitizens with end-stage
1134	1134	23 renal disease who are not eligible for comprehensive medical
1135	1135	24 benefits, who meet the residency requirements of Section 5-3
1136	1136	25 of this Code, and who would otherwise meet the financial
1137	1137	26 requirements of the appropriate class of eligible persons
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB4901 - 31 - LRB103 36276 KTG 66373 b
1144	1144
1145	1145
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1147	1147	HB4901 - 32 - LRB103 36276 KTG 66373 b
1148	1148	1 under Section 5-2 of this Code. To qualify for coverage of
1149	1149	2 kidney transplantation, such person must be receiving
1150	1150	3 emergency renal dialysis services covered by the Department.
1151	1151	4 Providers under this Section shall be prior approved and
1152	1152	5 certified by the Department to perform kidney transplantation
1153	1153	6 and the services under this Section shall be limited to
1154	1154	7 services associated with kidney transplantation.
1155	1155	8 Notwithstanding any other provision of this Code to the
1156	1156	9 contrary, on or after July 1, 2015, all FDA approved forms of
1157	1157	10 medication assisted treatment prescribed for the treatment of
1158	1158	11 alcohol dependence or treatment of opioid dependence shall be
1159	1159	12 covered under both fee-for-service fee for service and managed
1160	1160	13 care medical assistance programs for persons who are otherwise
1161	1161	14 eligible for medical assistance under this Article and shall
1162	1162	15 not be subject to any (1) utilization control, other than
1163	1163	16 those established under the American Society of Addiction
1164	1164	17 Medicine patient placement criteria, (2) prior authorization
1165	1165	18 mandate, or (3) lifetime restriction limit mandate.
1166	1166	19 On or after July 1, 2015, opioid antagonists prescribed
1167	1167	20 for the treatment of an opioid overdose, including the
1168	1168	21 medication product, administration devices, and any pharmacy
1169	1169	22 fees or hospital fees related to the dispensing, distribution,
1170	1170	23 and administration of the opioid antagonist, shall be covered
1171	1171	24 under the medical assistance program for persons who are
1172	1172	25 otherwise eligible for medical assistance under this Article.
1173	1173	26 As used in this Section, "opioid antagonist" means a drug that
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB4901 - 32 - LRB103 36276 KTG 66373 b
1180	1180
1181	1181
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1183	1183	HB4901 - 33 - LRB103 36276 KTG 66373 b
1184	1184	1 binds to opioid receptors and blocks or inhibits the effect of
1185	1185	2 opioids acting on those receptors, including, but not limited
1186	1186	3 to, naloxone hydrochloride or any other similarly acting drug
1187	1187	4 approved by the U.S. Food and Drug Administration. The
1188	1188	5 Department shall not impose a copayment on the coverage
1189	1189	6 provided for naloxone hydrochloride under the medical
1190	1190	7 assistance program.
1191	1191	8 Upon federal approval, the Department shall provide
1192	1192	9 coverage and reimbursement for all drugs that are approved for
1193	1193	10 marketing by the federal Food and Drug Administration and that
1194	1194	11 are recommended by the federal Public Health Service or the
1195	1195	12 United States Centers for Disease Control and Prevention for
1196	1196	13 pre-exposure prophylaxis and related pre-exposure prophylaxis
1197	1197	14 services, including, but not limited to, HIV and sexually
1198	1198	15 transmitted infection screening, treatment for sexually
1199	1199	16 transmitted infections, medical monitoring, assorted labs, and
1200	1200	17 counseling to reduce the likelihood of HIV infection among
1201	1201	18 individuals who are not infected with HIV but who are at high
1202	1202	19 risk of HIV infection.
1203	1203	20 A federally qualified health center, as defined in Section
1204	1204	21 1905(l)(2)(B) of the federal Social Security Act, shall be
1205	1205	22 reimbursed by the Department in accordance with the federally
1206	1206	23 qualified health center's encounter rate for services provided
1207	1207	24 to medical assistance recipients that are performed by a
1208	1208	25 dental hygienist, as defined under the Illinois Dental
1209	1209	26 Practice Act, working under the general supervision of a
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
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1216	1216
1217	1217
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1219	1219	HB4901 - 34 - LRB103 36276 KTG 66373 b
1220	1220	1 dentist and employed by a federally qualified health center.
1221	1221	2 Within 90 days after October 8, 2021 (the effective date
1222	1222	3 of Public Act 102-665), the Department shall seek federal
1223	1223	4 approval of a State Plan amendment to expand coverage for
1224	1224	5 family planning services that includes presumptive eligibility
1225	1225	6 to individuals whose income is at or below 208% of the federal
1226	1226	7 poverty level. Coverage under this Section shall be effective
1227	1227	8 beginning no later than December 1, 2022.
1228	1228	9 Subject to approval by the federal Centers for Medicare
1229	1229	10 and Medicaid Services of a Title XIX State Plan amendment
1230	1230	11 electing the Program of All-Inclusive Care for the Elderly
1231	1231	12 (PACE) as a State Medicaid option, as provided for by Subtitle
1232	1232	13 I (commencing with Section 4801) of Title IV of the Balanced
1233	1233	14 Budget Act of 1997 (Public Law 105-33) and Part 460
1234	1234	15 (commencing with Section 460.2) of Subchapter E of Title 42 of
1235	1235	16 the Code of Federal Regulations, PACE program services shall
1236	1236	17 become a covered benefit of the medical assistance program,
1237	1237	18 subject to criteria established in accordance with all
1238	1238	19 applicable laws.
1239	1239	20 Notwithstanding any other provision of this Code,
1240	1240	21 community-based pediatric palliative care from a trained
1241	1241	22 interdisciplinary team shall be covered under the medical
1242	1242	23 assistance program as provided in Section 15 of the Pediatric
1243	1243	24 Palliative Care Act.
1244	1244	25 Notwithstanding any other provision of this Code, within
1245	1245	26 12 months after June 2, 2022 (the effective date of Public Act
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
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1252	1252
1253	1253
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1256	1256	1 102-1037) and subject to federal approval, acupuncture
1257	1257	2 services performed by an acupuncturist licensed under the
1258	1258	3 Acupuncture Practice Act who is acting within the scope of his
1259	1259	4 or her license shall be covered under the medical assistance
1260	1260	5 program. The Department shall apply for any federal waiver or
1261	1261	6 State Plan amendment, if required, to implement this
1262	1262	7 paragraph. The Department may adopt any rules, including
1263	1263	8 standards and criteria, necessary to implement this paragraph.
1264	1264	9 Notwithstanding any other provision of this Code, the
1265	1265	10 medical assistance program shall, subject to appropriation and
1266	1266	11 federal approval, reimburse hospitals for costs associated
1267	1267	12 with a newborn screening test for the presence of
1268	1268	13 metachromatic leukodystrophy, as required under the Newborn
1269	1269	14 Metabolic Screening Act, at a rate not less than the fee
1270	1270	15 charged by the Department of Public Health. The Department
1271	1271	16 shall seek federal approval before the implementation of the
1272	1272	17 newborn screening test fees by the Department of Public
1273	1273	18 Health.
1274	1274	19 Notwithstanding any other provision of this Code,
1275	1275	20 beginning on January 1, 2024, subject to federal approval,
1276	1276	21 cognitive assessment and care planning services provided to a
1277	1277	22 person who experiences signs or symptoms of cognitive
1278	1278	23 impairment, as defined by the Diagnostic and Statistical
1279	1279	24 Manual of Mental Disorders, Fifth Edition, shall be covered
1280	1280	25 under the medical assistance program for persons who are
1281	1281	26 otherwise eligible for medical assistance under this Article.
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
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1288	1288
1289	1289
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1291	1291	HB4901 - 36 - LRB103 36276 KTG 66373 b
1292	1292	1 Notwithstanding any other provision of this Code,
1293	1293	2 medically necessary reconstructive services that are intended
1294	1294	3 to restore physical appearance shall be covered under the
1295	1295	4 medical assistance program for persons who are otherwise
1296	1296	5 eligible for medical assistance under this Article. As used in
1297	1297	6 this paragraph, "reconstructive services" means treatments
1298	1298	7 performed on structures of the body damaged by trauma to
1299	1299	8 restore physical appearance.
1300	1300	9 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1301	1301	10 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1302	1302	11 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1303	1303	12 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1304	1304	13 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1305	1305	14 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1306	1306	15 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1307	1307	16 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1308	1308	17 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1309	1309	18 1-1-24; revised 12-15-23.)
1310	1310
1311	1311
1312	1312
1313	1313
1314	1314
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