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Illinois Senate Bill SB0067

Illinois 2023-2024 Regular Session

Illinois Senate Bill SB0067 Compare Versions

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1-Public Act 103-0368
21 SB0067 EnrolledLRB103 04485 CPF 49491 b SB0067 Enrolled LRB103 04485 CPF 49491 b
32 SB0067 Enrolled LRB103 04485 CPF 49491 b
4-AN ACT concerning health.
5-Be it enacted by the People of the State of Illinois,
6-represented in the General Assembly:
7-Section 5. The Newborn Metabolic Screening Act is amended
8-by adding Section 3.5 as follows:
9-(410 ILCS 240/3.5 new)
10-Sec. 3.5. Metachromatic leukodystrophy.
11-(a) The Department shall provide all newborns with
12-screening tests for the presence of metachromatic
13-leukodystrophy. The testing shall begin within 6 months after
14-the occurrence of all of the following milestones:
15-(1) Unless the federal Food and Drug Administration
16-approves a screening test for metachromatic leukodystrophy
17-using dried blood spots, the development and validation of
18-a reliable methodology for screening newborns for
19-metachromatic leukodystrophy using dried blood spots and a
20-methodology for conducting quality assurance testing of
21-the screening test.
22-(2) The availability of any necessary reagent for a
23-metachromatic leukodystrophy screening test.
24-(3) The establishment and verification of relevant and
25-appropriate performance specifications as defined under
26-the federal Clinical Laboratory Improvement Amendments and
3+1 AN ACT concerning health.
4+2 Be it enacted by the People of the State of Illinois,
5+3 represented in the General Assembly:
6+4 Section 5. The Newborn Metabolic Screening Act is amended
7+5 by adding Section 3.5 as follows:
8+6 (410 ILCS 240/3.5 new)
9+7 Sec. 3.5. Metachromatic leukodystrophy.
10+8 (a) The Department shall provide all newborns with
11+9 screening tests for the presence of metachromatic
12+10 leukodystrophy. The testing shall begin within 6 months after
13+11 the occurrence of all of the following milestones:
14+12 (1) Unless the federal Food and Drug Administration
15+13 approves a screening test for metachromatic leukodystrophy
16+14 using dried blood spots, the development and validation of
17+15 a reliable methodology for screening newborns for
18+16 metachromatic leukodystrophy using dried blood spots and a
19+17 methodology for conducting quality assurance testing of
20+18 the screening test.
21+19 (2) The availability of any necessary reagent for a
22+20 metachromatic leukodystrophy screening test.
23+21 (3) The establishment and verification of relevant and
24+22 appropriate performance specifications as defined under
25+23 the federal Clinical Laboratory Improvement Amendments and
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33-regulations thereunder for Federal Drug
34-Administration-cleared or in-house developed methods,
35-performed under an institutional review board approved
36-protocol, if required.
37-(4) The availability of quality assurance testing and
38-comparative threshold values for metachromatic
39-leukodystrophy screening tests.
40-(5) The acquisition and installation by the Department
41-of equipment necessary to implement metachromatic
42-leukodystrophy screening tests.
43-(6) The establishment of precise threshold values
44-ensuring defined disorder identification of metachromatic
45-leukodystrophy.
46-(7) The authentication of pilot testing indicating
47-that each milestone described in paragraphs (1) through
48-(6) has been achieved.
49-(8) The authentication of achieving the potential of
50-high throughput standards for statewide volume of each
51-metachromatic leukodystrophy screening test concomitant
52-with each milestone described in paragraphs (1) through
53-(4).
54-(b) To accumulate the resources for the costs, including
55-start-up costs, associated with metachromatic leukodystrophy
56-screening tests and any follow-up programs, the Department may
57-require payment of an additional fee for administering a
58-metachromatic leukodystrophy screening test under this
32+SB0067 Enrolled- 2 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 2 - LRB103 04485 CPF 49491 b
33+ SB0067 Enrolled - 2 - LRB103 04485 CPF 49491 b
34+1 regulations thereunder for Federal Drug
35+2 Administration-cleared or in-house developed methods,
36+3 performed under an institutional review board approved
37+4 protocol, if required.
38+5 (4) The availability of quality assurance testing and
39+6 comparative threshold values for metachromatic
40+7 leukodystrophy screening tests.
41+8 (5) The acquisition and installation by the Department
42+9 of equipment necessary to implement metachromatic
43+10 leukodystrophy screening tests.
44+11 (6) The establishment of precise threshold values
45+12 ensuring defined disorder identification of metachromatic
46+13 leukodystrophy.
47+14 (7) The authentication of pilot testing indicating
48+15 that each milestone described in paragraphs (1) through
49+16 (6) has been achieved.
50+17 (8) The authentication of achieving the potential of
51+18 high throughput standards for statewide volume of each
52+19 metachromatic leukodystrophy screening test concomitant
53+20 with each milestone described in paragraphs (1) through
54+21 (4).
55+22 (b) To accumulate the resources for the costs, including
56+23 start-up costs, associated with metachromatic leukodystrophy
57+24 screening tests and any follow-up programs, the Department may
58+25 require payment of an additional fee for administering a
59+26 metachromatic leukodystrophy screening test under this
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61-Section. The Department may not require the payment of the
62-additional fee prior to 6 months before the Department
63-administers metachromatic leukodystrophy screening tests under
64-this Section.
65-Section 10. The Illinois Public Aid Code is amended by
66-changing Section 5-5 as follows:
67-(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
68-Sec. 5-5. Medical services. The Illinois Department, by
69-rule, shall determine the quantity and quality of and the rate
70-of reimbursement for the medical assistance for which payment
71-will be authorized, and the medical services to be provided,
72-which may include all or part of the following: (1) inpatient
73-hospital services; (2) outpatient hospital services; (3) other
74-laboratory and X-ray services; (4) skilled nursing home
75-services; (5) physicians' services whether furnished in the
76-office, the patient's home, a hospital, a skilled nursing
77-home, or elsewhere; (6) medical care, or any other type of
78-remedial care furnished by licensed practitioners; (7) home
79-health care services; (8) private duty nursing service; (9)
80-clinic services; (10) dental services, including prevention
81-and treatment of periodontal disease and dental caries disease
82-for pregnant individuals, provided by an individual licensed
83-to practice dentistry or dental surgery; for purposes of this
84-item (10), "dental services" means diagnostic, preventive, or
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87-corrective procedures provided by or under the supervision of
88-a dentist in the practice of his or her profession; (11)
89-physical therapy and related services; (12) prescribed drugs,
90-dentures, and prosthetic devices; and eyeglasses prescribed by
91-a physician skilled in the diseases of the eye, or by an
92-optometrist, whichever the person may select; (13) other
93-diagnostic, screening, preventive, and rehabilitative
94-services, including to ensure that the individual's need for
95-intervention or treatment of mental disorders or substance use
96-disorders or co-occurring mental health and substance use
97-disorders is determined using a uniform screening, assessment,
98-and evaluation process inclusive of criteria, for children and
99-adults; for purposes of this item (13), a uniform screening,
100-assessment, and evaluation process refers to a process that
101-includes an appropriate evaluation and, as warranted, a
102-referral; "uniform" does not mean the use of a singular
103-instrument, tool, or process that all must utilize; (14)
104-transportation and such other expenses as may be necessary;
105-(15) medical treatment of sexual assault survivors, as defined
106-in Section 1a of the Sexual Assault Survivors Emergency
107-Treatment Act, for injuries sustained as a result of the
108-sexual assault, including examinations and laboratory tests to
109-discover evidence which may be used in criminal proceedings
110-arising from the sexual assault; (16) the diagnosis and
111-treatment of sickle cell anemia; (16.5) services performed by
112-a chiropractic physician licensed under the Medical Practice
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115-Act of 1987 and acting within the scope of his or her license,
116-including, but not limited to, chiropractic manipulative
117-treatment; and (17) any other medical care, and any other type
118-of remedial care recognized under the laws of this State. The
119-term "any other type of remedial care" shall include nursing
120-care and nursing home service for persons who rely on
121-treatment by spiritual means alone through prayer for healing.
122-Notwithstanding any other provision of this Section, a
123-comprehensive tobacco use cessation program that includes
124-purchasing prescription drugs or prescription medical devices
125-approved by the Food and Drug Administration shall be covered
126-under the medical assistance program under this Article for
127-persons who are otherwise eligible for assistance under this
128-Article.
129-Notwithstanding any other provision of this Code,
130-reproductive health care that is otherwise legal in Illinois
131-shall be covered under the medical assistance program for
132-persons who are otherwise eligible for medical assistance
133-under this Article.
134-Notwithstanding any other provision of this Section, all
135-tobacco cessation medications approved by the United States
136-Food and Drug Administration and all individual and group
137-tobacco cessation counseling services and telephone-based
138-counseling services and tobacco cessation medications provided
139-through the Illinois Tobacco Quitline shall be covered under
140-the medical assistance program for persons who are otherwise
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70+1 Section. The Department may not require the payment of the
71+2 additional fee prior to 6 months before the Department
72+3 administers metachromatic leukodystrophy screening tests under
73+4 this Section.
74+5 Section 10. The Illinois Public Aid Code is amended by
75+6 changing Section 5-5 as follows:
76+7 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
77+8 Sec. 5-5. Medical services. The Illinois Department, by
78+9 rule, shall determine the quantity and quality of and the rate
79+10 of reimbursement for the medical assistance for which payment
80+11 will be authorized, and the medical services to be provided,
81+12 which may include all or part of the following: (1) inpatient
82+13 hospital services; (2) outpatient hospital services; (3) other
83+14 laboratory and X-ray services; (4) skilled nursing home
84+15 services; (5) physicians' services whether furnished in the
85+16 office, the patient's home, a hospital, a skilled nursing
86+17 home, or elsewhere; (6) medical care, or any other type of
87+18 remedial care furnished by licensed practitioners; (7) home
88+19 health care services; (8) private duty nursing service; (9)
89+20 clinic services; (10) dental services, including prevention
90+21 and treatment of periodontal disease and dental caries disease
91+22 for pregnant individuals, provided by an individual licensed
92+23 to practice dentistry or dental surgery; for purposes of this
93+24 item (10), "dental services" means diagnostic, preventive, or
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143-eligible for assistance under this Article. The Department
144-shall comply with all federal requirements necessary to obtain
145-federal financial participation, as specified in 42 CFR
146-433.15(b)(7), for telephone-based counseling services provided
147-through the Illinois Tobacco Quitline, including, but not
148-limited to: (i) entering into a memorandum of understanding or
149-interagency agreement with the Department of Public Health, as
150-administrator of the Illinois Tobacco Quitline; and (ii)
151-developing a cost allocation plan for Medicaid-allowable
152-Illinois Tobacco Quitline services in accordance with 45 CFR
153-95.507. The Department shall submit the memorandum of
154-understanding or interagency agreement, the cost allocation
155-plan, and all other necessary documentation to the Centers for
156-Medicare and Medicaid Services for review and approval.
157-Coverage under this paragraph shall be contingent upon federal
158-approval.
159-Notwithstanding any other provision of this Code, the
160-Illinois Department may not require, as a condition of payment
161-for any laboratory test authorized under this Article, that a
162-physician's handwritten signature appear on the laboratory
163-test order form. The Illinois Department may, however, impose
164-other appropriate requirements regarding laboratory test order
165-documentation.
166-Upon receipt of federal approval of an amendment to the
167-Illinois Title XIX State Plan for this purpose, the Department
168-shall authorize the Chicago Public Schools (CPS) to procure a
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171-vendor or vendors to manufacture eyeglasses for individuals
172-enrolled in a school within the CPS system. CPS shall ensure
173-that its vendor or vendors are enrolled as providers in the
174-medical assistance program and in any capitated Medicaid
175-managed care entity (MCE) serving individuals enrolled in a
176-school within the CPS system. Under any contract procured
177-under this provision, the vendor or vendors must serve only
178-individuals enrolled in a school within the CPS system. Claims
179-for services provided by CPS's vendor or vendors to recipients
180-of benefits in the medical assistance program under this Code,
181-the Children's Health Insurance Program, or the Covering ALL
182-KIDS Health Insurance Program shall be submitted to the
183-Department or the MCE in which the individual is enrolled for
184-payment and shall be reimbursed at the Department's or the
185-MCE's established rates or rate methodologies for eyeglasses.
186-On and after July 1, 2012, the Department of Healthcare
187-and Family Services may provide the following services to
188-persons eligible for assistance under this Article who are
189-participating in education, training or employment programs
190-operated by the Department of Human Services as successor to
191-the Department of Public Aid:
192-(1) dental services provided by or under the
193-supervision of a dentist; and
194-(2) eyeglasses prescribed by a physician skilled in
195-the diseases of the eye, or by an optometrist, whichever
196-the person may select.
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199-On and after July 1, 2018, the Department of Healthcare
200-and Family Services shall provide dental services to any adult
201-who is otherwise eligible for assistance under the medical
202-assistance program. As used in this paragraph, "dental
203-services" means diagnostic, preventative, restorative, or
204-corrective procedures, including procedures and services for
205-the prevention and treatment of periodontal disease and dental
206-caries disease, provided by an individual who is licensed to
207-practice dentistry or dental surgery or who is under the
208-supervision of a dentist in the practice of his or her
209-profession.
210-On and after July 1, 2018, targeted dental services, as
211-set forth in Exhibit D of the Consent Decree entered by the
212-United States District Court for the Northern District of
213-Illinois, Eastern Division, in the matter of Memisovski v.
214-Maram, Case No. 92 C 1982, that are provided to adults under
215-the medical assistance program shall be established at no less
216-than the rates set forth in the "New Rate" column in Exhibit D
217-of the Consent Decree for targeted dental services that are
218-provided to persons under the age of 18 under the medical
219-assistance program.
220-Notwithstanding any other provision of this Code and
221-subject to federal approval, the Department may adopt rules to
222-allow a dentist who is volunteering his or her service at no
223-cost to render dental services through an enrolled
224-not-for-profit health clinic without the dentist personally
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104+1 corrective procedures provided by or under the supervision of
105+2 a dentist in the practice of his or her profession; (11)
106+3 physical therapy and related services; (12) prescribed drugs,
107+4 dentures, and prosthetic devices; and eyeglasses prescribed by
108+5 a physician skilled in the diseases of the eye, or by an
109+6 optometrist, whichever the person may select; (13) other
110+7 diagnostic, screening, preventive, and rehabilitative
111+8 services, including to ensure that the individual's need for
112+9 intervention or treatment of mental disorders or substance use
113+10 disorders or co-occurring mental health and substance use
114+11 disorders is determined using a uniform screening, assessment,
115+12 and evaluation process inclusive of criteria, for children and
116+13 adults; for purposes of this item (13), a uniform screening,
117+14 assessment, and evaluation process refers to a process that
118+15 includes an appropriate evaluation and, as warranted, a
119+16 referral; "uniform" does not mean the use of a singular
120+17 instrument, tool, or process that all must utilize; (14)
121+18 transportation and such other expenses as may be necessary;
122+19 (15) medical treatment of sexual assault survivors, as defined
123+20 in Section 1a of the Sexual Assault Survivors Emergency
124+21 Treatment Act, for injuries sustained as a result of the
125+22 sexual assault, including examinations and laboratory tests to
126+23 discover evidence which may be used in criminal proceedings
127+24 arising from the sexual assault; (16) the diagnosis and
128+25 treatment of sickle cell anemia; (16.5) services performed by
129+26 a chiropractic physician licensed under the Medical Practice
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227-enrolling as a participating provider in the medical
228-assistance program. A not-for-profit health clinic shall
229-include a public health clinic or Federally Qualified Health
230-Center or other enrolled provider, as determined by the
231-Department, through which dental services covered under this
232-Section are performed. The Department shall establish a
233-process for payment of claims for reimbursement for covered
234-dental services rendered under this provision.
235-On and after January 1, 2022, the Department of Healthcare
236-and Family Services shall administer and regulate a
237-school-based dental program that allows for the out-of-office
238-delivery of preventative dental services in a school setting
239-to children under 19 years of age. The Department shall
240-establish, by rule, guidelines for participation by providers
241-and set requirements for follow-up referral care based on the
242-requirements established in the Dental Office Reference Manual
243-published by the Department that establishes the requirements
244-for dentists participating in the All Kids Dental School
245-Program. Every effort shall be made by the Department when
246-developing the program requirements to consider the different
247-geographic differences of both urban and rural areas of the
248-State for initial treatment and necessary follow-up care. No
249-provider shall be charged a fee by any unit of local government
250-to participate in the school-based dental program administered
251-by the Department. Nothing in this paragraph shall be
252-construed to limit or preempt a home rule unit's or school
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255-district's authority to establish, change, or administer a
256-school-based dental program in addition to, or independent of,
257-the school-based dental program administered by the
258-Department.
259-The Illinois Department, by rule, may distinguish and
260-classify the medical services to be provided only in
261-accordance with the classes of persons designated in Section
262-5-2.
263-The Department of Healthcare and Family Services must
264-provide coverage and reimbursement for amino acid-based
265-elemental formulas, regardless of delivery method, for the
266-diagnosis and treatment of (i) eosinophilic disorders and (ii)
267-short bowel syndrome when the prescribing physician has issued
268-a written order stating that the amino acid-based elemental
269-formula is medically necessary.
270-The Illinois Department shall authorize the provision of,
271-and shall authorize payment for, screening by low-dose
272-mammography for the presence of occult breast cancer for
273-individuals 35 years of age or older who are eligible for
274-medical assistance under this Article, as follows:
275-(A) A baseline mammogram for individuals 35 to 39
276-years of age.
277-(B) An annual mammogram for individuals 40 years of
278-age or older.
279-(C) A mammogram at the age and intervals considered
280-medically necessary by the individual's health care
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283-provider for individuals under 40 years of age and having
284-a family history of breast cancer, prior personal history
285-of breast cancer, positive genetic testing, or other risk
286-factors.
287-(D) A comprehensive ultrasound screening and MRI of an
288-entire breast or breasts if a mammogram demonstrates
289-heterogeneous or dense breast tissue or when medically
290-necessary as determined by a physician licensed to
291-practice medicine in all of its branches.
292-(E) A screening MRI when medically necessary, as
293-determined by a physician licensed to practice medicine in
294-all of its branches.
295-(F) A diagnostic mammogram when medically necessary,
296-as determined by a physician licensed to practice medicine
297-in all its branches, advanced practice registered nurse,
298-or physician assistant.
299-The Department shall not impose a deductible, coinsurance,
300-copayment, or any other cost-sharing requirement on the
301-coverage provided under this paragraph; except that this
302-sentence does not apply to coverage of diagnostic mammograms
303-to the extent such coverage would disqualify a high-deductible
304-health plan from eligibility for a health savings account
305-pursuant to Section 223 of the Internal Revenue Code (26
306-U.S.C. 223).
307-All screenings shall include a physical breast exam,
308-instruction on self-examination and information regarding the
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140+1 Act of 1987 and acting within the scope of his or her license,
141+2 including, but not limited to, chiropractic manipulative
142+3 treatment; and (17) any other medical care, and any other type
143+4 of remedial care recognized under the laws of this State. The
144+5 term "any other type of remedial care" shall include nursing
145+6 care and nursing home service for persons who rely on
146+7 treatment by spiritual means alone through prayer for healing.
147+8 Notwithstanding any other provision of this Section, a
148+9 comprehensive tobacco use cessation program that includes
149+10 purchasing prescription drugs or prescription medical devices
150+11 approved by the Food and Drug Administration shall be covered
151+12 under the medical assistance program under this Article for
152+13 persons who are otherwise eligible for assistance under this
153+14 Article.
154+15 Notwithstanding any other provision of this Code,
155+16 reproductive health care that is otherwise legal in Illinois
156+17 shall be covered under the medical assistance program for
157+18 persons who are otherwise eligible for medical assistance
158+19 under this Article.
159+20 Notwithstanding any other provision of this Section, all
160+21 tobacco cessation medications approved by the United States
161+22 Food and Drug Administration and all individual and group
162+23 tobacco cessation counseling services and telephone-based
163+24 counseling services and tobacco cessation medications provided
164+25 through the Illinois Tobacco Quitline shall be covered under
165+26 the medical assistance program for persons who are otherwise
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311-frequency of self-examination and its value as a preventative
312-tool.
313-For purposes of this Section:
314-"Diagnostic mammogram" means a mammogram obtained using
315-diagnostic mammography.
316-"Diagnostic mammography" means a method of screening that
317-is designed to evaluate an abnormality in a breast, including
318-an abnormality seen or suspected on a screening mammogram or a
319-subjective or objective abnormality otherwise detected in the
320-breast.
321-"Low-dose mammography" means the x-ray examination of the
322-breast using equipment dedicated specifically for mammography,
323-including the x-ray tube, filter, compression device, and
324-image receptor, with an average radiation exposure delivery of
325-less than one rad per breast for 2 views of an average size
326-breast. The term also includes digital mammography and
327-includes breast tomosynthesis.
328-"Breast tomosynthesis" means a radiologic procedure that
329-involves the acquisition of projection images over the
330-stationary breast to produce cross-sectional digital
331-three-dimensional images of the breast.
332-If, at any time, the Secretary of the United States
333-Department of Health and Human Services, or its successor
334-agency, promulgates rules or regulations to be published in
335-the Federal Register or publishes a comment in the Federal
336-Register or issues an opinion, guidance, or other action that
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339-would require the State, pursuant to any provision of the
340-Patient Protection and Affordable Care Act (Public Law
341-111-148), including, but not limited to, 42 U.S.C.
342-18031(d)(3)(B) or any successor provision, to defray the cost
343-of any coverage for breast tomosynthesis outlined in this
344-paragraph, then the requirement that an insurer cover breast
345-tomosynthesis is inoperative other than any such coverage
346-authorized under Section 1902 of the Social Security Act, 42
347-U.S.C. 1396a, and the State shall not assume any obligation
348-for the cost of coverage for breast tomosynthesis set forth in
349-this paragraph.
350-On and after January 1, 2016, the Department shall ensure
351-that all networks of care for adult clients of the Department
352-include access to at least one breast imaging Center of
353-Imaging Excellence as certified by the American College of
354-Radiology.
355-On and after January 1, 2012, providers participating in a
356-quality improvement program approved by the Department shall
357-be reimbursed for screening and diagnostic mammography at the
358-same rate as the Medicare program's rates, including the
359-increased reimbursement for digital mammography and, after
360-January 1, 2023 (the effective date of Public Act 102-1018)
361-this amendatory Act of the 102nd General Assembly, breast
362-tomosynthesis.
363-The Department shall convene an expert panel including
364-representatives of hospitals, free-standing mammography
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367-facilities, and doctors, including radiologists, to establish
368-quality standards for mammography.
369-On and after January 1, 2017, providers participating in a
370-breast cancer treatment quality improvement program approved
371-by the Department shall be reimbursed for breast cancer
372-treatment at a rate that is no lower than 95% of the Medicare
373-program's rates for the data elements included in the breast
374-cancer treatment quality program.
375-The Department shall convene an expert panel, including
376-representatives of hospitals, free-standing breast cancer
377-treatment centers, breast cancer quality organizations, and
378-doctors, including breast surgeons, reconstructive breast
379-surgeons, oncologists, and primary care providers to establish
380-quality standards for breast cancer treatment.
381-Subject to federal approval, the Department shall
382-establish a rate methodology for mammography at federally
383-qualified health centers and other encounter-rate clinics.
384-These clinics or centers may also collaborate with other
385-hospital-based mammography facilities. By January 1, 2016, the
386-Department shall report to the General Assembly on the status
387-of the provision set forth in this paragraph.
388-The Department shall establish a methodology to remind
389-individuals who are age-appropriate for screening mammography,
390-but who have not received a mammogram within the previous 18
391-months, of the importance and benefit of screening
392-mammography. The Department shall work with experts in breast
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176+1 eligible for assistance under this Article. The Department
177+2 shall comply with all federal requirements necessary to obtain
178+3 federal financial participation, as specified in 42 CFR
179+4 433.15(b)(7), for telephone-based counseling services provided
180+5 through the Illinois Tobacco Quitline, including, but not
181+6 limited to: (i) entering into a memorandum of understanding or
182+7 interagency agreement with the Department of Public Health, as
183+8 administrator of the Illinois Tobacco Quitline; and (ii)
184+9 developing a cost allocation plan for Medicaid-allowable
185+10 Illinois Tobacco Quitline services in accordance with 45 CFR
186+11 95.507. The Department shall submit the memorandum of
187+12 understanding or interagency agreement, the cost allocation
188+13 plan, and all other necessary documentation to the Centers for
189+14 Medicare and Medicaid Services for review and approval.
190+15 Coverage under this paragraph shall be contingent upon federal
191+16 approval.
192+17 Notwithstanding any other provision of this Code, the
193+18 Illinois Department may not require, as a condition of payment
194+19 for any laboratory test authorized under this Article, that a
195+20 physician's handwritten signature appear on the laboratory
196+21 test order form. The Illinois Department may, however, impose
197+22 other appropriate requirements regarding laboratory test order
198+23 documentation.
199+24 Upon receipt of federal approval of an amendment to the
200+25 Illinois Title XIX State Plan for this purpose, the Department
201+26 shall authorize the Chicago Public Schools (CPS) to procure a
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395-cancer outreach and patient navigation to optimize these
396-reminders and shall establish a methodology for evaluating
397-their effectiveness and modifying the methodology based on the
398-evaluation.
399-The Department shall establish a performance goal for
400-primary care providers with respect to their female patients
401-over age 40 receiving an annual mammogram. This performance
402-goal shall be used to provide additional reimbursement in the
403-form of a quality performance bonus to primary care providers
404-who meet that goal.
405-The Department shall devise a means of case-managing or
406-patient navigation for beneficiaries diagnosed with breast
407-cancer. This program shall initially operate as a pilot
408-program in areas of the State with the highest incidence of
409-mortality related to breast cancer. At least one pilot program
410-site shall be in the metropolitan Chicago area and at least one
411-site shall be outside the metropolitan Chicago area. On or
412-after July 1, 2016, the pilot program shall be expanded to
413-include one site in western Illinois, one site in southern
414-Illinois, one site in central Illinois, and 4 sites within
415-metropolitan Chicago. An evaluation of the pilot program shall
416-be carried out measuring health outcomes and cost of care for
417-those served by the pilot program compared to similarly
418-situated patients who are not served by the pilot program.
419-The Department shall require all networks of care to
420-develop a means either internally or by contract with experts
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423-in navigation and community outreach to navigate cancer
424-patients to comprehensive care in a timely fashion. The
425-Department shall require all networks of care to include
426-access for patients diagnosed with cancer to at least one
427-academic commission on cancer-accredited cancer program as an
428-in-network covered benefit.
429-The Department shall provide coverage and reimbursement
430-for a human papillomavirus (HPV) vaccine that is approved for
431-marketing by the federal Food and Drug Administration for all
432-persons between the ages of 9 and 45 and persons of the age of
433-46 and above who have been diagnosed with cervical dysplasia
434-with a high risk of recurrence or progression. The Department
435-shall disallow any preauthorization requirements for the
436-administration of the human papillomavirus (HPV) vaccine.
437-On or after July 1, 2022, individuals who are otherwise
438-eligible for medical assistance under this Article shall
439-receive coverage for perinatal depression screenings for the
440-12-month period beginning on the last day of their pregnancy.
441-Medical assistance coverage under this paragraph shall be
442-conditioned on the use of a screening instrument approved by
443-the Department.
444-Any medical or health care provider shall immediately
445-recommend, to any pregnant individual who is being provided
446-prenatal services and is suspected of having a substance use
447-disorder as defined in the Substance Use Disorder Act,
448-referral to a local substance use disorder treatment program
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451-licensed by the Department of Human Services or to a licensed
452-hospital which provides substance abuse treatment services.
453-The Department of Healthcare and Family Services shall assure
454-coverage for the cost of treatment of the drug abuse or
455-addiction for pregnant recipients in accordance with the
456-Illinois Medicaid Program in conjunction with the Department
457-of Human Services.
458-All medical providers providing medical assistance to
459-pregnant individuals under this Code shall receive information
460-from the Department on the availability of services under any
461-program providing case management services for addicted
462-individuals, including information on appropriate referrals
463-for other social services that may be needed by addicted
464-individuals in addition to treatment for addiction.
465-The Illinois Department, in cooperation with the
466-Departments of Human Services (as successor to the Department
467-of Alcoholism and Substance Abuse) and Public Health, through
468-a public awareness campaign, may provide information
469-concerning treatment for alcoholism and drug abuse and
470-addiction, prenatal health care, and other pertinent programs
471-directed at reducing the number of drug-affected infants born
472-to recipients of medical assistance.
473-Neither the Department of Healthcare and Family Services
474-nor the Department of Human Services shall sanction the
475-recipient solely on the basis of the recipient's substance
476-abuse.
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211+ SB0067 Enrolled - 7 - LRB103 04485 CPF 49491 b
212+1 vendor or vendors to manufacture eyeglasses for individuals
213+2 enrolled in a school within the CPS system. CPS shall ensure
214+3 that its vendor or vendors are enrolled as providers in the
215+4 medical assistance program and in any capitated Medicaid
216+5 managed care entity (MCE) serving individuals enrolled in a
217+6 school within the CPS system. Under any contract procured
218+7 under this provision, the vendor or vendors must serve only
219+8 individuals enrolled in a school within the CPS system. Claims
220+9 for services provided by CPS's vendor or vendors to recipients
221+10 of benefits in the medical assistance program under this Code,
222+11 the Children's Health Insurance Program, or the Covering ALL
223+12 KIDS Health Insurance Program shall be submitted to the
224+13 Department or the MCE in which the individual is enrolled for
225+14 payment and shall be reimbursed at the Department's or the
226+15 MCE's established rates or rate methodologies for eyeglasses.
227+16 On and after July 1, 2012, the Department of Healthcare
228+17 and Family Services may provide the following services to
229+18 persons eligible for assistance under this Article who are
230+19 participating in education, training or employment programs
231+20 operated by the Department of Human Services as successor to
232+21 the Department of Public Aid:
233+22 (1) dental services provided by or under the
234+23 supervision of a dentist; and
235+24 (2) eyeglasses prescribed by a physician skilled in
236+25 the diseases of the eye, or by an optometrist, whichever
237+26 the person may select.
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478239
479-The Illinois Department shall establish such regulations
480-governing the dispensing of health services under this Article
481-as it shall deem appropriate. The Department should seek the
482-advice of formal professional advisory committees appointed by
483-the Director of the Illinois Department for the purpose of
484-providing regular advice on policy and administrative matters,
485-information dissemination and educational activities for
486-medical and health care providers, and consistency in
487-procedures to the Illinois Department.
488-The Illinois Department may develop and contract with
489-Partnerships of medical providers to arrange medical services
490-for persons eligible under Section 5-2 of this Code.
491-Implementation of this Section may be by demonstration
492-projects in certain geographic areas. The Partnership shall be
493-represented by a sponsor organization. The Department, by
494-rule, shall develop qualifications for sponsors of
495-Partnerships. Nothing in this Section shall be construed to
496-require that the sponsor organization be a medical
497-organization.
498-The sponsor must negotiate formal written contracts with
499-medical providers for physician services, inpatient and
500-outpatient hospital care, home health services, treatment for
501-alcoholism and substance abuse, and other services determined
502-necessary by the Illinois Department by rule for delivery by
503-Partnerships. Physician services must include prenatal and
504-obstetrical care. The Illinois Department shall reimburse
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506241
507-medical services delivered by Partnership providers to clients
508-in target areas according to provisions of this Article and
509-the Illinois Health Finance Reform Act, except that:
510-(1) Physicians participating in a Partnership and
511-providing certain services, which shall be determined by
512-the Illinois Department, to persons in areas covered by
513-the Partnership may receive an additional surcharge for
514-such services.
515-(2) The Department may elect to consider and negotiate
516-financial incentives to encourage the development of
517-Partnerships and the efficient delivery of medical care.
518-(3) Persons receiving medical services through
519-Partnerships may receive medical and case management
520-services above the level usually offered through the
521-medical assistance program.
522-Medical providers shall be required to meet certain
523-qualifications to participate in Partnerships to ensure the
524-delivery of high quality medical services. These
525-qualifications shall be determined by rule of the Illinois
526-Department and may be higher than qualifications for
527-participation in the medical assistance program. Partnership
528-sponsors may prescribe reasonable additional qualifications
529-for participation by medical providers, only with the prior
530-written approval of the Illinois Department.
531-Nothing in this Section shall limit the free choice of
532-practitioners, hospitals, and other providers of medical
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535-services by clients. In order to ensure patient freedom of
536-choice, the Illinois Department shall immediately promulgate
537-all rules and take all other necessary actions so that
538-provided services may be accessed from therapeutically
539-certified optometrists to the full extent of the Illinois
540-Optometric Practice Act of 1987 without discriminating between
541-service providers.
542-The Department shall apply for a waiver from the United
543-States Health Care Financing Administration to allow for the
544-implementation of Partnerships under this Section.
545-The Illinois Department shall require health care
546-providers to maintain records that document the medical care
547-and services provided to recipients of Medical Assistance
548-under this Article. Such records must be retained for a period
549-of not less than 6 years from the date of service or as
550-provided by applicable State law, whichever period is longer,
551-except that if an audit is initiated within the required
552-retention period then the records must be retained until the
553-audit is completed and every exception is resolved. The
554-Illinois Department shall require health care providers to
555-make available, when authorized by the patient, in writing,
556-the medical records in a timely fashion to other health care
557-providers who are treating or serving persons eligible for
558-Medical Assistance under this Article. All dispensers of
559-medical services shall be required to maintain and retain
560-business and professional records sufficient to fully and
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247+ SB0067 Enrolled - 8 - LRB103 04485 CPF 49491 b
248+1 On and after July 1, 2018, the Department of Healthcare
249+2 and Family Services shall provide dental services to any adult
250+3 who is otherwise eligible for assistance under the medical
251+4 assistance program. As used in this paragraph, "dental
252+5 services" means diagnostic, preventative, restorative, or
253+6 corrective procedures, including procedures and services for
254+7 the prevention and treatment of periodontal disease and dental
255+8 caries disease, provided by an individual who is licensed to
256+9 practice dentistry or dental surgery or who is under the
257+10 supervision of a dentist in the practice of his or her
258+11 profession.
259+12 On and after July 1, 2018, targeted dental services, as
260+13 set forth in Exhibit D of the Consent Decree entered by the
261+14 United States District Court for the Northern District of
262+15 Illinois, Eastern Division, in the matter of Memisovski v.
263+16 Maram, Case No. 92 C 1982, that are provided to adults under
264+17 the medical assistance program shall be established at no less
265+18 than the rates set forth in the "New Rate" column in Exhibit D
266+19 of the Consent Decree for targeted dental services that are
267+20 provided to persons under the age of 18 under the medical
268+21 assistance program.
269+22 Notwithstanding any other provision of this Code and
270+23 subject to federal approval, the Department may adopt rules to
271+24 allow a dentist who is volunteering his or her service at no
272+25 cost to render dental services through an enrolled
273+26 not-for-profit health clinic without the dentist personally
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563-accurately document the nature, scope, details and receipt of
564-the health care provided to persons eligible for medical
565-assistance under this Code, in accordance with regulations
566-promulgated by the Illinois Department. The rules and
567-regulations shall require that proof of the receipt of
568-prescription drugs, dentures, prosthetic devices and
569-eyeglasses by eligible persons under this Section accompany
570-each claim for reimbursement submitted by the dispenser of
571-such medical services. No such claims for reimbursement shall
572-be approved for payment by the Illinois Department without
573-such proof of receipt, unless the Illinois Department shall
574-have put into effect and shall be operating a system of
575-post-payment audit and review which shall, on a sampling
576-basis, be deemed adequate by the Illinois Department to assure
577-that such drugs, dentures, prosthetic devices and eyeglasses
578-for which payment is being made are actually being received by
579-eligible recipients. Within 90 days after September 16, 1984
580-(the effective date of Public Act 83-1439), the Illinois
581-Department shall establish a current list of acquisition costs
582-for all prosthetic devices and any other items recognized as
583-medical equipment and supplies reimbursable under this Article
584-and shall update such list on a quarterly basis, except that
585-the acquisition costs of all prescription drugs shall be
586-updated no less frequently than every 30 days as required by
587-Section 5-5.12.
588-Notwithstanding any other law to the contrary, the
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591-Illinois Department shall, within 365 days after July 22, 2013
592-(the effective date of Public Act 98-104), establish
593-procedures to permit skilled care facilities licensed under
594-the Nursing Home Care Act to submit monthly billing claims for
595-reimbursement purposes. Following development of these
596-procedures, the Department shall, by July 1, 2016, test the
597-viability of the new system and implement any necessary
598-operational or structural changes to its information
599-technology platforms in order to allow for the direct
600-acceptance and payment of nursing home claims.
601-Notwithstanding any other law to the contrary, the
602-Illinois Department shall, within 365 days after August 15,
603-2014 (the effective date of Public Act 98-963), establish
604-procedures to permit ID/DD facilities licensed under the ID/DD
605-Community Care Act and MC/DD facilities licensed under the
606-MC/DD Act to submit monthly billing claims for reimbursement
607-purposes. Following development of these procedures, the
608-Department shall have an additional 365 days to test the
609-viability of the new system and to ensure that any necessary
610-operational or structural changes to its information
611-technology platforms are implemented.
612-The Illinois Department shall require all dispensers of
613-medical services, other than an individual practitioner or
614-group of practitioners, desiring to participate in the Medical
615-Assistance program established under this Article to disclose
616-all financial, beneficial, ownership, equity, surety or other
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619-interests in any and all firms, corporations, partnerships,
620-associations, business enterprises, joint ventures, agencies,
621-institutions or other legal entities providing any form of
622-health care services in this State under this Article.
623-The Illinois Department may require that all dispensers of
624-medical services desiring to participate in the medical
625-assistance program established under this Article disclose,
626-under such terms and conditions as the Illinois Department may
627-by rule establish, all inquiries from clients and attorneys
628-regarding medical bills paid by the Illinois Department, which
629-inquiries could indicate potential existence of claims or
630-liens for the Illinois Department.
631-Enrollment of a vendor shall be subject to a provisional
632-period and shall be conditional for one year. During the
633-period of conditional enrollment, the Department may terminate
634-the vendor's eligibility to participate in, or may disenroll
635-the vendor from, the medical assistance program without cause.
636-Unless otherwise specified, such termination of eligibility or
637-disenrollment is not subject to the Department's hearing
638-process. However, a disenrolled vendor may reapply without
639-penalty.
640-The Department has the discretion to limit the conditional
641-enrollment period for vendors based upon the category of risk
642-of the vendor.
643-Prior to enrollment and during the conditional enrollment
644-period in the medical assistance program, all vendors shall be
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283+ SB0067 Enrolled - 9 - LRB103 04485 CPF 49491 b
284+1 enrolling as a participating provider in the medical
285+2 assistance program. A not-for-profit health clinic shall
286+3 include a public health clinic or Federally Qualified Health
287+4 Center or other enrolled provider, as determined by the
288+5 Department, through which dental services covered under this
289+6 Section are performed. The Department shall establish a
290+7 process for payment of claims for reimbursement for covered
291+8 dental services rendered under this provision.
292+9 On and after January 1, 2022, the Department of Healthcare
293+10 and Family Services shall administer and regulate a
294+11 school-based dental program that allows for the out-of-office
295+12 delivery of preventative dental services in a school setting
296+13 to children under 19 years of age. The Department shall
297+14 establish, by rule, guidelines for participation by providers
298+15 and set requirements for follow-up referral care based on the
299+16 requirements established in the Dental Office Reference Manual
300+17 published by the Department that establishes the requirements
301+18 for dentists participating in the All Kids Dental School
302+19 Program. Every effort shall be made by the Department when
303+20 developing the program requirements to consider the different
304+21 geographic differences of both urban and rural areas of the
305+22 State for initial treatment and necessary follow-up care. No
306+23 provider shall be charged a fee by any unit of local government
307+24 to participate in the school-based dental program administered
308+25 by the Department. Nothing in this paragraph shall be
309+26 construed to limit or preempt a home rule unit's or school
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647-subject to enhanced oversight, screening, and review based on
648-the risk of fraud, waste, and abuse that is posed by the
649-category of risk of the vendor. The Illinois Department shall
650-establish the procedures for oversight, screening, and review,
651-which may include, but need not be limited to: criminal and
652-financial background checks; fingerprinting; license,
653-certification, and authorization verifications; unscheduled or
654-unannounced site visits; database checks; prepayment audit
655-reviews; audits; payment caps; payment suspensions; and other
656-screening as required by federal or State law.
657-The Department shall define or specify the following: (i)
658-by provider notice, the "category of risk of the vendor" for
659-each type of vendor, which shall take into account the level of
660-screening applicable to a particular category of vendor under
661-federal law and regulations; (ii) by rule or provider notice,
662-the maximum length of the conditional enrollment period for
663-each category of risk of the vendor; and (iii) by rule, the
664-hearing rights, if any, afforded to a vendor in each category
665-of risk of the vendor that is terminated or disenrolled during
666-the conditional enrollment period.
667-To be eligible for payment consideration, a vendor's
668-payment claim or bill, either as an initial claim or as a
669-resubmitted claim following prior rejection, must be received
670-by the Illinois Department, or its fiscal intermediary, no
671-later than 180 days after the latest date on the claim on which
672-medical goods or services were provided, with the following
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675-exceptions:
676-(1) In the case of a provider whose enrollment is in
677-process by the Illinois Department, the 180-day period
678-shall not begin until the date on the written notice from
679-the Illinois Department that the provider enrollment is
680-complete.
681-(2) In the case of errors attributable to the Illinois
682-Department or any of its claims processing intermediaries
683-which result in an inability to receive, process, or
684-adjudicate a claim, the 180-day period shall not begin
685-until the provider has been notified of the error.
686-(3) In the case of a provider for whom the Illinois
687-Department initiates the monthly billing process.
688-(4) In the case of a provider operated by a unit of
689-local government with a population exceeding 3,000,000
690-when local government funds finance federal participation
691-for claims payments.
692-For claims for services rendered during a period for which
693-a recipient received retroactive eligibility, claims must be
694-filed within 180 days after the Department determines the
695-applicant is eligible. For claims for which the Illinois
696-Department is not the primary payer, claims must be submitted
697-to the Illinois Department within 180 days after the final
698-adjudication by the primary payer.
699-In the case of long term care facilities, within 120
700-calendar days of receipt by the facility of required
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703-prescreening information, new admissions with associated
704-admission documents shall be submitted through the Medical
705-Electronic Data Interchange (MEDI) or the Recipient
706-Eligibility Verification (REV) System or shall be submitted
707-directly to the Department of Human Services using required
708-admission forms. Effective September 1, 2014, admission
709-documents, including all prescreening information, must be
710-submitted through MEDI or REV. Confirmation numbers assigned
711-to an accepted transaction shall be retained by a facility to
712-verify timely submittal. Once an admission transaction has
713-been completed, all resubmitted claims following prior
714-rejection are subject to receipt no later than 180 days after
715-the admission transaction has been completed.
716-Claims that are not submitted and received in compliance
717-with the foregoing requirements shall not be eligible for
718-payment under the medical assistance program, and the State
719-shall have no liability for payment of those claims.
720-To the extent consistent with applicable information and
721-privacy, security, and disclosure laws, State and federal
722-agencies and departments shall provide the Illinois Department
723-access to confidential and other information and data
724-necessary to perform eligibility and payment verifications and
725-other Illinois Department functions. This includes, but is not
726-limited to: information pertaining to licensure;
727-certification; earnings; immigration status; citizenship; wage
728-reporting; unearned and earned income; pension income;
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320+1 district's authority to establish, change, or administer a
321+2 school-based dental program in addition to, or independent of,
322+3 the school-based dental program administered by the
323+4 Department.
324+5 The Illinois Department, by rule, may distinguish and
325+6 classify the medical services to be provided only in
326+7 accordance with the classes of persons designated in Section
327+8 5-2.
328+9 The Department of Healthcare and Family Services must
329+10 provide coverage and reimbursement for amino acid-based
330+11 elemental formulas, regardless of delivery method, for the
331+12 diagnosis and treatment of (i) eosinophilic disorders and (ii)
332+13 short bowel syndrome when the prescribing physician has issued
333+14 a written order stating that the amino acid-based elemental
334+15 formula is medically necessary.
335+16 The Illinois Department shall authorize the provision of,
336+17 and shall authorize payment for, screening by low-dose
337+18 mammography for the presence of occult breast cancer for
338+19 individuals 35 years of age or older who are eligible for
339+20 medical assistance under this Article, as follows:
340+21 (A) A baseline mammogram for individuals 35 to 39
341+22 years of age.
342+23 (B) An annual mammogram for individuals 40 years of
343+24 age or older.
344+25 (C) A mammogram at the age and intervals considered
345+26 medically necessary by the individual's health care
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731-employment; supplemental security income; social security
732-numbers; National Provider Identifier (NPI) numbers; the
733-National Practitioner Data Bank (NPDB); program and agency
734-exclusions; taxpayer identification numbers; tax delinquency;
735-corporate information; and death records.
736-The Illinois Department shall enter into agreements with
737-State agencies and departments, and is authorized to enter
738-into agreements with federal agencies and departments, under
739-which such agencies and departments shall share data necessary
740-for medical assistance program integrity functions and
741-oversight. The Illinois Department shall develop, in
742-cooperation with other State departments and agencies, and in
743-compliance with applicable federal laws and regulations,
744-appropriate and effective methods to share such data. At a
745-minimum, and to the extent necessary to provide data sharing,
746-the Illinois Department shall enter into agreements with State
747-agencies and departments, and is authorized to enter into
748-agreements with federal agencies and departments, including,
749-but not limited to: the Secretary of State; the Department of
750-Revenue; the Department of Public Health; the Department of
751-Human Services; and the Department of Financial and
752-Professional Regulation.
753-Beginning in fiscal year 2013, the Illinois Department
754-shall set forth a request for information to identify the
755-benefits of a pre-payment, post-adjudication, and post-edit
756-claims system with the goals of streamlining claims processing
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759-and provider reimbursement, reducing the number of pending or
760-rejected claims, and helping to ensure a more transparent
761-adjudication process through the utilization of: (i) provider
762-data verification and provider screening technology; and (ii)
763-clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
764-or post-adjudicated predictive modeling with an integrated
765-case management system with link analysis. Such a request for
766-information shall not be considered as a request for proposal
767-or as an obligation on the part of the Illinois Department to
768-take any action or acquire any products or services.
769-The Illinois Department shall establish policies,
770-procedures, standards and criteria by rule for the
771-acquisition, repair and replacement of orthotic and prosthetic
772-devices and durable medical equipment. Such rules shall
773-provide, but not be limited to, the following services: (1)
774-immediate repair or replacement of such devices by recipients;
775-and (2) rental, lease, purchase or lease-purchase of durable
776-medical equipment in a cost-effective manner, taking into
777-consideration the recipient's medical prognosis, the extent of
778-the recipient's needs, and the requirements and costs for
779-maintaining such equipment. Subject to prior approval, such
780-rules shall enable a recipient to temporarily acquire and use
781-alternative or substitute devices or equipment pending repairs
782-or replacements of any device or equipment previously
783-authorized for such recipient by the Department.
784-Notwithstanding any provision of Section 5-5f to the contrary,
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787-the Department may, by rule, exempt certain replacement
788-wheelchair parts from prior approval and, for wheelchairs,
789-wheelchair parts, wheelchair accessories, and related seating
790-and positioning items, determine the wholesale price by
791-methods other than actual acquisition costs.
792-The Department shall require, by rule, all providers of
793-durable medical equipment to be accredited by an accreditation
794-organization approved by the federal Centers for Medicare and
795-Medicaid Services and recognized by the Department in order to
796-bill the Department for providing durable medical equipment to
797-recipients. No later than 15 months after the effective date
798-of the rule adopted pursuant to this paragraph, all providers
799-must meet the accreditation requirement.
800-In order to promote environmental responsibility, meet the
801-needs of recipients and enrollees, and achieve significant
802-cost savings, the Department, or a managed care organization
803-under contract with the Department, may provide recipients or
804-managed care enrollees who have a prescription or Certificate
805-of Medical Necessity access to refurbished durable medical
806-equipment under this Section (excluding prosthetic and
807-orthotic devices as defined in the Orthotics, Prosthetics, and
808-Pedorthics Practice Act and complex rehabilitation technology
809-products and associated services) through the State's
810-assistive technology program's reutilization program, using
811-staff with the Assistive Technology Professional (ATP)
812-Certification if the refurbished durable medical equipment:
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356+1 provider for individuals under 40 years of age and having
357+2 a family history of breast cancer, prior personal history
358+3 of breast cancer, positive genetic testing, or other risk
359+4 factors.
360+5 (D) A comprehensive ultrasound screening and MRI of an
361+6 entire breast or breasts if a mammogram demonstrates
362+7 heterogeneous or dense breast tissue or when medically
363+8 necessary as determined by a physician licensed to
364+9 practice medicine in all of its branches.
365+10 (E) A screening MRI when medically necessary, as
366+11 determined by a physician licensed to practice medicine in
367+12 all of its branches.
368+13 (F) A diagnostic mammogram when medically necessary,
369+14 as determined by a physician licensed to practice medicine
370+15 in all its branches, advanced practice registered nurse,
371+16 or physician assistant.
372+17 The Department shall not impose a deductible, coinsurance,
373+18 copayment, or any other cost-sharing requirement on the
374+19 coverage provided under this paragraph; except that this
375+20 sentence does not apply to coverage of diagnostic mammograms
376+21 to the extent such coverage would disqualify a high-deductible
377+22 health plan from eligibility for a health savings account
378+23 pursuant to Section 223 of the Internal Revenue Code (26
379+24 U.S.C. 223).
380+25 All screenings shall include a physical breast exam,
381+26 instruction on self-examination and information regarding the
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815-(i) is available; (ii) is less expensive, including shipping
816-costs, than new durable medical equipment of the same type;
817-(iii) is able to withstand at least 3 years of use; (iv) is
818-cleaned, disinfected, sterilized, and safe in accordance with
819-federal Food and Drug Administration regulations and guidance
820-governing the reprocessing of medical devices in health care
821-settings; and (v) equally meets the needs of the recipient or
822-enrollee. The reutilization program shall confirm that the
823-recipient or enrollee is not already in receipt of the same or
824-similar equipment from another service provider, and that the
825-refurbished durable medical equipment equally meets the needs
826-of the recipient or enrollee. Nothing in this paragraph shall
827-be construed to limit recipient or enrollee choice to obtain
828-new durable medical equipment or place any additional prior
829-authorization conditions on enrollees of managed care
830-organizations.
831-The Department shall execute, relative to the nursing home
832-prescreening project, written inter-agency agreements with the
833-Department of Human Services and the Department on Aging, to
834-effect the following: (i) intake procedures and common
835-eligibility criteria for those persons who are receiving
836-non-institutional services; and (ii) the establishment and
837-development of non-institutional services in areas of the
838-State where they are not currently available or are
839-undeveloped; and (iii) notwithstanding any other provision of
840-law, subject to federal approval, on and after July 1, 2012, an
841384
842385
843-increase in the determination of need (DON) scores from 29 to
844-37 for applicants for institutional and home and
845-community-based long term care; if and only if federal
846-approval is not granted, the Department may, in conjunction
847-with other affected agencies, implement utilization controls
848-or changes in benefit packages to effectuate a similar savings
849-amount for this population; and (iv) no later than July 1,
850-2013, minimum level of care eligibility criteria for
851-institutional and home and community-based long term care; and
852-(v) no later than October 1, 2013, establish procedures to
853-permit long term care providers access to eligibility scores
854-for individuals with an admission date who are seeking or
855-receiving services from the long term care provider. In order
856-to select the minimum level of care eligibility criteria, the
857-Governor shall establish a workgroup that includes affected
858-agency representatives and stakeholders representing the
859-institutional and home and community-based long term care
860-interests. This Section shall not restrict the Department from
861-implementing lower level of care eligibility criteria for
862-community-based services in circumstances where federal
863-approval has been granted.
864-The Illinois Department shall develop and operate, in
865-cooperation with other State Departments and agencies and in
866-compliance with applicable federal laws and regulations,
867-appropriate and effective systems of health care evaluation
868-and programs for monitoring of utilization of health care
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871-services and facilities, as it affects persons eligible for
872-medical assistance under this Code.
873-The Illinois Department shall report annually to the
874-General Assembly, no later than the second Friday in April of
875-1979 and each year thereafter, in regard to:
876-(a) actual statistics and trends in utilization of
877-medical services by public aid recipients;
878-(b) actual statistics and trends in the provision of
879-the various medical services by medical vendors;
880-(c) current rate structures and proposed changes in
881-those rate structures for the various medical vendors; and
882-(d) efforts at utilization review and control by the
883-Illinois Department.
884-The period covered by each report shall be the 3 years
885-ending on the June 30 prior to the report. The report shall
886-include suggested legislation for consideration by the General
887-Assembly. The requirement for reporting to the General
888-Assembly shall be satisfied by filing copies of the report as
889-required by Section 3.1 of the General Assembly Organization
890-Act, and filing such additional copies with the State
891-Government Report Distribution Center for the General Assembly
892-as is required under paragraph (t) of Section 7 of the State
893-Library Act.
894-Rulemaking authority to implement Public Act 95-1045, if
895-any, is conditioned on the rules being adopted in accordance
896-with all provisions of the Illinois Administrative Procedure
390+SB0067 Enrolled- 12 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 12 - LRB103 04485 CPF 49491 b
391+ SB0067 Enrolled - 12 - LRB103 04485 CPF 49491 b
392+1 frequency of self-examination and its value as a preventative
393+2 tool.
394+3 For purposes of this Section:
395+4 "Diagnostic mammogram" means a mammogram obtained using
396+5 diagnostic mammography.
397+6 "Diagnostic mammography" means a method of screening that
398+7 is designed to evaluate an abnormality in a breast, including
399+8 an abnormality seen or suspected on a screening mammogram or a
400+9 subjective or objective abnormality otherwise detected in the
401+10 breast.
402+11 "Low-dose mammography" means the x-ray examination of the
403+12 breast using equipment dedicated specifically for mammography,
404+13 including the x-ray tube, filter, compression device, and
405+14 image receptor, with an average radiation exposure delivery of
406+15 less than one rad per breast for 2 views of an average size
407+16 breast. The term also includes digital mammography and
408+17 includes breast tomosynthesis.
409+18 "Breast tomosynthesis" means a radiologic procedure that
410+19 involves the acquisition of projection images over the
411+20 stationary breast to produce cross-sectional digital
412+21 three-dimensional images of the breast.
413+22 If, at any time, the Secretary of the United States
414+23 Department of Health and Human Services, or its successor
415+24 agency, promulgates rules or regulations to be published in
416+25 the Federal Register or publishes a comment in the Federal
417+26 Register or issues an opinion, guidance, or other action that
897418
898419
899-Act and all rules and procedures of the Joint Committee on
900-Administrative Rules; any purported rule not so adopted, for
901-whatever reason, is unauthorized.
902-On and after July 1, 2012, the Department shall reduce any
903-rate of reimbursement for services or other payments or alter
904-any methodologies authorized by this Code to reduce any rate
905-of reimbursement for services or other payments in accordance
906-with Section 5-5e.
907-Because kidney transplantation can be an appropriate,
908-cost-effective alternative to renal dialysis when medically
909-necessary and notwithstanding the provisions of Section 1-11
910-of this Code, beginning October 1, 2014, the Department shall
911-cover kidney transplantation for noncitizens with end-stage
912-renal disease who are not eligible for comprehensive medical
913-benefits, who meet the residency requirements of Section 5-3
914-of this Code, and who would otherwise meet the financial
915-requirements of the appropriate class of eligible persons
916-under Section 5-2 of this Code. To qualify for coverage of
917-kidney transplantation, such person must be receiving
918-emergency renal dialysis services covered by the Department.
919-Providers under this Section shall be prior approved and
920-certified by the Department to perform kidney transplantation
921-and the services under this Section shall be limited to
922-services associated with kidney transplantation.
923-Notwithstanding any other provision of this Code to the
924-contrary, on or after July 1, 2015, all FDA approved forms of
925420
926421
927-medication assisted treatment prescribed for the treatment of
928-alcohol dependence or treatment of opioid dependence shall be
929-covered under both fee for service and managed care medical
930-assistance programs for persons who are otherwise eligible for
931-medical assistance under this Article and shall not be subject
932-to any (1) utilization control, other than those established
933-under the American Society of Addiction Medicine patient
934-placement criteria, (2) prior authorization mandate, or (3)
935-lifetime restriction limit mandate.
936-On or after July 1, 2015, opioid antagonists prescribed
937-for the treatment of an opioid overdose, including the
938-medication product, administration devices, and any pharmacy
939-fees or hospital fees related to the dispensing, distribution,
940-and administration of the opioid antagonist, shall be covered
941-under the medical assistance program for persons who are
942-otherwise eligible for medical assistance under this Article.
943-As used in this Section, "opioid antagonist" means a drug that
944-binds to opioid receptors and blocks or inhibits the effect of
945-opioids acting on those receptors, including, but not limited
946-to, naloxone hydrochloride or any other similarly acting drug
947-approved by the U.S. Food and Drug Administration. The
948-Department shall not impose a copayment on the coverage
949-provided for naloxone hydrochloride under the medical
950-assistance program.
951-Upon federal approval, the Department shall provide
952-coverage and reimbursement for all drugs that are approved for
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955-marketing by the federal Food and Drug Administration and that
956-are recommended by the federal Public Health Service or the
957-United States Centers for Disease Control and Prevention for
958-pre-exposure prophylaxis and related pre-exposure prophylaxis
959-services, including, but not limited to, HIV and sexually
960-transmitted infection screening, treatment for sexually
961-transmitted infections, medical monitoring, assorted labs, and
962-counseling to reduce the likelihood of HIV infection among
963-individuals who are not infected with HIV but who are at high
964-risk of HIV infection.
965-A federally qualified health center, as defined in Section
966-1905(l)(2)(B) of the federal Social Security Act, shall be
967-reimbursed by the Department in accordance with the federally
968-qualified health center's encounter rate for services provided
969-to medical assistance recipients that are performed by a
970-dental hygienist, as defined under the Illinois Dental
971-Practice Act, working under the general supervision of a
972-dentist and employed by a federally qualified health center.
973-Within 90 days after October 8, 2021 (the effective date
974-of Public Act 102-665), the Department shall seek federal
975-approval of a State Plan amendment to expand coverage for
976-family planning services that includes presumptive eligibility
977-to individuals whose income is at or below 208% of the federal
978-poverty level. Coverage under this Section shall be effective
979-beginning no later than December 1, 2022.
980-Subject to approval by the federal Centers for Medicare
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427+ SB0067 Enrolled - 13 - LRB103 04485 CPF 49491 b
428+1 would require the State, pursuant to any provision of the
429+2 Patient Protection and Affordable Care Act (Public Law
430+3 111-148), including, but not limited to, 42 U.S.C.
431+4 18031(d)(3)(B) or any successor provision, to defray the cost
432+5 of any coverage for breast tomosynthesis outlined in this
433+6 paragraph, then the requirement that an insurer cover breast
434+7 tomosynthesis is inoperative other than any such coverage
435+8 authorized under Section 1902 of the Social Security Act, 42
436+9 U.S.C. 1396a, and the State shall not assume any obligation
437+10 for the cost of coverage for breast tomosynthesis set forth in
438+11 this paragraph.
439+12 On and after January 1, 2016, the Department shall ensure
440+13 that all networks of care for adult clients of the Department
441+14 include access to at least one breast imaging Center of
442+15 Imaging Excellence as certified by the American College of
443+16 Radiology.
444+17 On and after January 1, 2012, providers participating in a
445+18 quality improvement program approved by the Department shall
446+19 be reimbursed for screening and diagnostic mammography at the
447+20 same rate as the Medicare program's rates, including the
448+21 increased reimbursement for digital mammography and, after
449+22 January 1, 2023 (the effective date of Public Act 102-1018)
450+23 this amendatory Act of the 102nd General Assembly, breast
451+24 tomosynthesis.
452+25 The Department shall convene an expert panel including
453+26 representatives of hospitals, free-standing mammography
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982455
983-and Medicaid Services of a Title XIX State Plan amendment
984-electing the Program of All-Inclusive Care for the Elderly
985-(PACE) as a State Medicaid option, as provided for by Subtitle
986-I (commencing with Section 4801) of Title IV of the Balanced
987-Budget Act of 1997 (Public Law 105-33) and Part 460
988-(commencing with Section 460.2) of Subchapter E of Title 42 of
989-the Code of Federal Regulations, PACE program services shall
990-become a covered benefit of the medical assistance program,
991-subject to criteria established in accordance with all
992-applicable laws.
993-Notwithstanding any other provision of this Code,
994-community-based pediatric palliative care from a trained
995-interdisciplinary team shall be covered under the medical
996-assistance program as provided in Section 15 of the Pediatric
997-Palliative
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464+1 facilities, and doctors, including radiologists, to establish
465+2 quality standards for mammography.
466+3 On and after January 1, 2017, providers participating in a
467+4 breast cancer treatment quality improvement program approved
468+5 by the Department shall be reimbursed for breast cancer
469+6 treatment at a rate that is no lower than 95% of the Medicare
470+7 program's rates for the data elements included in the breast
471+8 cancer treatment quality program.
472+9 The Department shall convene an expert panel, including
473+10 representatives of hospitals, free-standing breast cancer
474+11 treatment centers, breast cancer quality organizations, and
475+12 doctors, including breast surgeons, reconstructive breast
476+13 surgeons, oncologists, and primary care providers to establish
477+14 quality standards for breast cancer treatment.
478+15 Subject to federal approval, the Department shall
479+16 establish a rate methodology for mammography at federally
480+17 qualified health centers and other encounter-rate clinics.
481+18 These clinics or centers may also collaborate with other
482+19 hospital-based mammography facilities. By January 1, 2016, the
483+20 Department shall report to the General Assembly on the status
484+21 of the provision set forth in this paragraph.
485+22 The Department shall establish a methodology to remind
486+23 individuals who are age-appropriate for screening mammography,
487+24 but who have not received a mammogram within the previous 18
488+25 months, of the importance and benefit of screening
489+26 mammography. The Department shall work with experts in breast
490+
491+
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500+1 cancer outreach and patient navigation to optimize these
501+2 reminders and shall establish a methodology for evaluating
502+3 their effectiveness and modifying the methodology based on the
503+4 evaluation.
504+5 The Department shall establish a performance goal for
505+6 primary care providers with respect to their female patients
506+7 over age 40 receiving an annual mammogram. This performance
507+8 goal shall be used to provide additional reimbursement in the
508+9 form of a quality performance bonus to primary care providers
509+10 who meet that goal.
510+11 The Department shall devise a means of case-managing or
511+12 patient navigation for beneficiaries diagnosed with breast
512+13 cancer. This program shall initially operate as a pilot
513+14 program in areas of the State with the highest incidence of
514+15 mortality related to breast cancer. At least one pilot program
515+16 site shall be in the metropolitan Chicago area and at least one
516+17 site shall be outside the metropolitan Chicago area. On or
517+18 after July 1, 2016, the pilot program shall be expanded to
518+19 include one site in western Illinois, one site in southern
519+20 Illinois, one site in central Illinois, and 4 sites within
520+21 metropolitan Chicago. An evaluation of the pilot program shall
521+22 be carried out measuring health outcomes and cost of care for
522+23 those served by the pilot program compared to similarly
523+24 situated patients who are not served by the pilot program.
524+25 The Department shall require all networks of care to
525+26 develop a means either internally or by contract with experts
526+
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536+1 in navigation and community outreach to navigate cancer
537+2 patients to comprehensive care in a timely fashion. The
538+3 Department shall require all networks of care to include
539+4 access for patients diagnosed with cancer to at least one
540+5 academic commission on cancer-accredited cancer program as an
541+6 in-network covered benefit.
542+7 The Department shall provide coverage and reimbursement
543+8 for a human papillomavirus (HPV) vaccine that is approved for
544+9 marketing by the federal Food and Drug Administration for all
545+10 persons between the ages of 9 and 45 and persons of the age of
546+11 46 and above who have been diagnosed with cervical dysplasia
547+12 with a high risk of recurrence or progression. The Department
548+13 shall disallow any preauthorization requirements for the
549+14 administration of the human papillomavirus (HPV) vaccine.
550+15 On or after July 1, 2022, individuals who are otherwise
551+16 eligible for medical assistance under this Article shall
552+17 receive coverage for perinatal depression screenings for the
553+18 12-month period beginning on the last day of their pregnancy.
554+19 Medical assistance coverage under this paragraph shall be
555+20 conditioned on the use of a screening instrument approved by
556+21 the Department.
557+22 Any medical or health care provider shall immediately
558+23 recommend, to any pregnant individual who is being provided
559+24 prenatal services and is suspected of having a substance use
560+25 disorder as defined in the Substance Use Disorder Act,
561+26 referral to a local substance use disorder treatment program
562+
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572+1 licensed by the Department of Human Services or to a licensed
573+2 hospital which provides substance abuse treatment services.
574+3 The Department of Healthcare and Family Services shall assure
575+4 coverage for the cost of treatment of the drug abuse or
576+5 addiction for pregnant recipients in accordance with the
577+6 Illinois Medicaid Program in conjunction with the Department
578+7 of Human Services.
579+8 All medical providers providing medical assistance to
580+9 pregnant individuals under this Code shall receive information
581+10 from the Department on the availability of services under any
582+11 program providing case management services for addicted
583+12 individuals, including information on appropriate referrals
584+13 for other social services that may be needed by addicted
585+14 individuals in addition to treatment for addiction.
586+15 The Illinois Department, in cooperation with the
587+16 Departments of Human Services (as successor to the Department
588+17 of Alcoholism and Substance Abuse) and Public Health, through
589+18 a public awareness campaign, may provide information
590+19 concerning treatment for alcoholism and drug abuse and
591+20 addiction, prenatal health care, and other pertinent programs
592+21 directed at reducing the number of drug-affected infants born
593+22 to recipients of medical assistance.
594+23 Neither the Department of Healthcare and Family Services
595+24 nor the Department of Human Services shall sanction the
596+25 recipient solely on the basis of the recipient's substance
597+26 abuse.
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608+1 The Illinois Department shall establish such regulations
609+2 governing the dispensing of health services under this Article
610+3 as it shall deem appropriate. The Department should seek the
611+4 advice of formal professional advisory committees appointed by
612+5 the Director of the Illinois Department for the purpose of
613+6 providing regular advice on policy and administrative matters,
614+7 information dissemination and educational activities for
615+8 medical and health care providers, and consistency in
616+9 procedures to the Illinois Department.
617+10 The Illinois Department may develop and contract with
618+11 Partnerships of medical providers to arrange medical services
619+12 for persons eligible under Section 5-2 of this Code.
620+13 Implementation of this Section may be by demonstration
621+14 projects in certain geographic areas. The Partnership shall be
622+15 represented by a sponsor organization. The Department, by
623+16 rule, shall develop qualifications for sponsors of
624+17 Partnerships. Nothing in this Section shall be construed to
625+18 require that the sponsor organization be a medical
626+19 organization.
627+20 The sponsor must negotiate formal written contracts with
628+21 medical providers for physician services, inpatient and
629+22 outpatient hospital care, home health services, treatment for
630+23 alcoholism and substance abuse, and other services determined
631+24 necessary by the Illinois Department by rule for delivery by
632+25 Partnerships. Physician services must include prenatal and
633+26 obstetrical care. The Illinois Department shall reimburse
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644+1 medical services delivered by Partnership providers to clients
645+2 in target areas according to provisions of this Article and
646+3 the Illinois Health Finance Reform Act, except that:
647+4 (1) Physicians participating in a Partnership and
648+5 providing certain services, which shall be determined by
649+6 the Illinois Department, to persons in areas covered by
650+7 the Partnership may receive an additional surcharge for
651+8 such services.
652+9 (2) The Department may elect to consider and negotiate
653+10 financial incentives to encourage the development of
654+11 Partnerships and the efficient delivery of medical care.
655+12 (3) Persons receiving medical services through
656+13 Partnerships may receive medical and case management
657+14 services above the level usually offered through the
658+15 medical assistance program.
659+16 Medical providers shall be required to meet certain
660+17 qualifications to participate in Partnerships to ensure the
661+18 delivery of high quality medical services. These
662+19 qualifications shall be determined by rule of the Illinois
663+20 Department and may be higher than qualifications for
664+21 participation in the medical assistance program. Partnership
665+22 sponsors may prescribe reasonable additional qualifications
666+23 for participation by medical providers, only with the prior
667+24 written approval of the Illinois Department.
668+25 Nothing in this Section shall limit the free choice of
669+26 practitioners, hospitals, and other providers of medical
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680+1 services by clients. In order to ensure patient freedom of
681+2 choice, the Illinois Department shall immediately promulgate
682+3 all rules and take all other necessary actions so that
683+4 provided services may be accessed from therapeutically
684+5 certified optometrists to the full extent of the Illinois
685+6 Optometric Practice Act of 1987 without discriminating between
686+7 service providers.
687+8 The Department shall apply for a waiver from the United
688+9 States Health Care Financing Administration to allow for the
689+10 implementation of Partnerships under this Section.
690+11 The Illinois Department shall require health care
691+12 providers to maintain records that document the medical care
692+13 and services provided to recipients of Medical Assistance
693+14 under this Article. Such records must be retained for a period
694+15 of not less than 6 years from the date of service or as
695+16 provided by applicable State law, whichever period is longer,
696+17 except that if an audit is initiated within the required
697+18 retention period then the records must be retained until the
698+19 audit is completed and every exception is resolved. The
699+20 Illinois Department shall require health care providers to
700+21 make available, when authorized by the patient, in writing,
701+22 the medical records in a timely fashion to other health care
702+23 providers who are treating or serving persons eligible for
703+24 Medical Assistance under this Article. All dispensers of
704+25 medical services shall be required to maintain and retain
705+26 business and professional records sufficient to fully and
706+
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716+1 accurately document the nature, scope, details and receipt of
717+2 the health care provided to persons eligible for medical
718+3 assistance under this Code, in accordance with regulations
719+4 promulgated by the Illinois Department. The rules and
720+5 regulations shall require that proof of the receipt of
721+6 prescription drugs, dentures, prosthetic devices and
722+7 eyeglasses by eligible persons under this Section accompany
723+8 each claim for reimbursement submitted by the dispenser of
724+9 such medical services. No such claims for reimbursement shall
725+10 be approved for payment by the Illinois Department without
726+11 such proof of receipt, unless the Illinois Department shall
727+12 have put into effect and shall be operating a system of
728+13 post-payment audit and review which shall, on a sampling
729+14 basis, be deemed adequate by the Illinois Department to assure
730+15 that such drugs, dentures, prosthetic devices and eyeglasses
731+16 for which payment is being made are actually being received by
732+17 eligible recipients. Within 90 days after September 16, 1984
733+18 (the effective date of Public Act 83-1439), the Illinois
734+19 Department shall establish a current list of acquisition costs
735+20 for all prosthetic devices and any other items recognized as
736+21 medical equipment and supplies reimbursable under this Article
737+22 and shall update such list on a quarterly basis, except that
738+23 the acquisition costs of all prescription drugs shall be
739+24 updated no less frequently than every 30 days as required by
740+25 Section 5-5.12.
741+26 Notwithstanding any other law to the contrary, the
742+
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752+1 Illinois Department shall, within 365 days after July 22, 2013
753+2 (the effective date of Public Act 98-104), establish
754+3 procedures to permit skilled care facilities licensed under
755+4 the Nursing Home Care Act to submit monthly billing claims for
756+5 reimbursement purposes. Following development of these
757+6 procedures, the Department shall, by July 1, 2016, test the
758+7 viability of the new system and implement any necessary
759+8 operational or structural changes to its information
760+9 technology platforms in order to allow for the direct
761+10 acceptance and payment of nursing home claims.
762+11 Notwithstanding any other law to the contrary, the
763+12 Illinois Department shall, within 365 days after August 15,
764+13 2014 (the effective date of Public Act 98-963), establish
765+14 procedures to permit ID/DD facilities licensed under the ID/DD
766+15 Community Care Act and MC/DD facilities licensed under the
767+16 MC/DD Act to submit monthly billing claims for reimbursement
768+17 purposes. Following development of these procedures, the
769+18 Department shall have an additional 365 days to test the
770+19 viability of the new system and to ensure that any necessary
771+20 operational or structural changes to its information
772+21 technology platforms are implemented.
773+22 The Illinois Department shall require all dispensers of
774+23 medical services, other than an individual practitioner or
775+24 group of practitioners, desiring to participate in the Medical
776+25 Assistance program established under this Article to disclose
777+26 all financial, beneficial, ownership, equity, surety or other
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788+1 interests in any and all firms, corporations, partnerships,
789+2 associations, business enterprises, joint ventures, agencies,
790+3 institutions or other legal entities providing any form of
791+4 health care services in this State under this Article.
792+5 The Illinois Department may require that all dispensers of
793+6 medical services desiring to participate in the medical
794+7 assistance program established under this Article disclose,
795+8 under such terms and conditions as the Illinois Department may
796+9 by rule establish, all inquiries from clients and attorneys
797+10 regarding medical bills paid by the Illinois Department, which
798+11 inquiries could indicate potential existence of claims or
799+12 liens for the Illinois Department.
800+13 Enrollment of a vendor shall be subject to a provisional
801+14 period and shall be conditional for one year. During the
802+15 period of conditional enrollment, the Department may terminate
803+16 the vendor's eligibility to participate in, or may disenroll
804+17 the vendor from, the medical assistance program without cause.
805+18 Unless otherwise specified, such termination of eligibility or
806+19 disenrollment is not subject to the Department's hearing
807+20 process. However, a disenrolled vendor may reapply without
808+21 penalty.
809+22 The Department has the discretion to limit the conditional
810+23 enrollment period for vendors based upon the category of risk
811+24 of the vendor.
812+25 Prior to enrollment and during the conditional enrollment
813+26 period in the medical assistance program, all vendors shall be
814+
815+
816+
817+
818+
819+ SB0067 Enrolled - 23 - LRB103 04485 CPF 49491 b
820+
821+
822+SB0067 Enrolled- 24 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 24 - LRB103 04485 CPF 49491 b
823+ SB0067 Enrolled - 24 - LRB103 04485 CPF 49491 b
824+1 subject to enhanced oversight, screening, and review based on
825+2 the risk of fraud, waste, and abuse that is posed by the
826+3 category of risk of the vendor. The Illinois Department shall
827+4 establish the procedures for oversight, screening, and review,
828+5 which may include, but need not be limited to: criminal and
829+6 financial background checks; fingerprinting; license,
830+7 certification, and authorization verifications; unscheduled or
831+8 unannounced site visits; database checks; prepayment audit
832+9 reviews; audits; payment caps; payment suspensions; and other
833+10 screening as required by federal or State law.
834+11 The Department shall define or specify the following: (i)
835+12 by provider notice, the "category of risk of the vendor" for
836+13 each type of vendor, which shall take into account the level of
837+14 screening applicable to a particular category of vendor under
838+15 federal law and regulations; (ii) by rule or provider notice,
839+16 the maximum length of the conditional enrollment period for
840+17 each category of risk of the vendor; and (iii) by rule, the
841+18 hearing rights, if any, afforded to a vendor in each category
842+19 of risk of the vendor that is terminated or disenrolled during
843+20 the conditional enrollment period.
844+21 To be eligible for payment consideration, a vendor's
845+22 payment claim or bill, either as an initial claim or as a
846+23 resubmitted claim following prior rejection, must be received
847+24 by the Illinois Department, or its fiscal intermediary, no
848+25 later than 180 days after the latest date on the claim on which
849+26 medical goods or services were provided, with the following
850+
851+
852+
853+
854+
855+ SB0067 Enrolled - 24 - LRB103 04485 CPF 49491 b
856+
857+
858+SB0067 Enrolled- 25 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 25 - LRB103 04485 CPF 49491 b
859+ SB0067 Enrolled - 25 - LRB103 04485 CPF 49491 b
860+1 exceptions:
861+2 (1) In the case of a provider whose enrollment is in
862+3 process by the Illinois Department, the 180-day period
863+4 shall not begin until the date on the written notice from
864+5 the Illinois Department that the provider enrollment is
865+6 complete.
866+7 (2) In the case of errors attributable to the Illinois
867+8 Department or any of its claims processing intermediaries
868+9 which result in an inability to receive, process, or
869+10 adjudicate a claim, the 180-day period shall not begin
870+11 until the provider has been notified of the error.
871+12 (3) In the case of a provider for whom the Illinois
872+13 Department initiates the monthly billing process.
873+14 (4) In the case of a provider operated by a unit of
874+15 local government with a population exceeding 3,000,000
875+16 when local government funds finance federal participation
876+17 for claims payments.
877+18 For claims for services rendered during a period for which
878+19 a recipient received retroactive eligibility, claims must be
879+20 filed within 180 days after the Department determines the
880+21 applicant is eligible. For claims for which the Illinois
881+22 Department is not the primary payer, claims must be submitted
882+23 to the Illinois Department within 180 days after the final
883+24 adjudication by the primary payer.
884+25 In the case of long term care facilities, within 120
885+26 calendar days of receipt by the facility of required
886+
887+
888+
889+
890+
891+ SB0067 Enrolled - 25 - LRB103 04485 CPF 49491 b
892+
893+
894+SB0067 Enrolled- 26 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 26 - LRB103 04485 CPF 49491 b
895+ SB0067 Enrolled - 26 - LRB103 04485 CPF 49491 b
896+1 prescreening information, new admissions with associated
897+2 admission documents shall be submitted through the Medical
898+3 Electronic Data Interchange (MEDI) or the Recipient
899+4 Eligibility Verification (REV) System or shall be submitted
900+5 directly to the Department of Human Services using required
901+6 admission forms. Effective September 1, 2014, admission
902+7 documents, including all prescreening information, must be
903+8 submitted through MEDI or REV. Confirmation numbers assigned
904+9 to an accepted transaction shall be retained by a facility to
905+10 verify timely submittal. Once an admission transaction has
906+11 been completed, all resubmitted claims following prior
907+12 rejection are subject to receipt no later than 180 days after
908+13 the admission transaction has been completed.
909+14 Claims that are not submitted and received in compliance
910+15 with the foregoing requirements shall not be eligible for
911+16 payment under the medical assistance program, and the State
912+17 shall have no liability for payment of those claims.
913+18 To the extent consistent with applicable information and
914+19 privacy, security, and disclosure laws, State and federal
915+20 agencies and departments shall provide the Illinois Department
916+21 access to confidential and other information and data
917+22 necessary to perform eligibility and payment verifications and
918+23 other Illinois Department functions. This includes, but is not
919+24 limited to: information pertaining to licensure;
920+25 certification; earnings; immigration status; citizenship; wage
921+26 reporting; unearned and earned income; pension income;
922+
923+
924+
925+
926+
927+ SB0067 Enrolled - 26 - LRB103 04485 CPF 49491 b
928+
929+
930+SB0067 Enrolled- 27 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 27 - LRB103 04485 CPF 49491 b
931+ SB0067 Enrolled - 27 - LRB103 04485 CPF 49491 b
932+1 employment; supplemental security income; social security
933+2 numbers; National Provider Identifier (NPI) numbers; the
934+3 National Practitioner Data Bank (NPDB); program and agency
935+4 exclusions; taxpayer identification numbers; tax delinquency;
936+5 corporate information; and death records.
937+6 The Illinois Department shall enter into agreements with
938+7 State agencies and departments, and is authorized to enter
939+8 into agreements with federal agencies and departments, under
940+9 which such agencies and departments shall share data necessary
941+10 for medical assistance program integrity functions and
942+11 oversight. The Illinois Department shall develop, in
943+12 cooperation with other State departments and agencies, and in
944+13 compliance with applicable federal laws and regulations,
945+14 appropriate and effective methods to share such data. At a
946+15 minimum, and to the extent necessary to provide data sharing,
947+16 the Illinois Department shall enter into agreements with State
948+17 agencies and departments, and is authorized to enter into
949+18 agreements with federal agencies and departments, including,
950+19 but not limited to: the Secretary of State; the Department of
951+20 Revenue; the Department of Public Health; the Department of
952+21 Human Services; and the Department of Financial and
953+22 Professional Regulation.
954+23 Beginning in fiscal year 2013, the Illinois Department
955+24 shall set forth a request for information to identify the
956+25 benefits of a pre-payment, post-adjudication, and post-edit
957+26 claims system with the goals of streamlining claims processing
958+
959+
960+
961+
962+
963+ SB0067 Enrolled - 27 - LRB103 04485 CPF 49491 b
964+
965+
966+SB0067 Enrolled- 28 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 28 - LRB103 04485 CPF 49491 b
967+ SB0067 Enrolled - 28 - LRB103 04485 CPF 49491 b
968+1 and provider reimbursement, reducing the number of pending or
969+2 rejected claims, and helping to ensure a more transparent
970+3 adjudication process through the utilization of: (i) provider
971+4 data verification and provider screening technology; and (ii)
972+5 clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
973+6 or post-adjudicated predictive modeling with an integrated
974+7 case management system with link analysis. Such a request for
975+8 information shall not be considered as a request for proposal
976+9 or as an obligation on the part of the Illinois Department to
977+10 take any action or acquire any products or services.
978+11 The Illinois Department shall establish policies,
979+12 procedures, standards and criteria by rule for the
980+13 acquisition, repair and replacement of orthotic and prosthetic
981+14 devices and durable medical equipment. Such rules shall
982+15 provide, but not be limited to, the following services: (1)
983+16 immediate repair or replacement of such devices by recipients;
984+17 and (2) rental, lease, purchase or lease-purchase of durable
985+18 medical equipment in a cost-effective manner, taking into
986+19 consideration the recipient's medical prognosis, the extent of
987+20 the recipient's needs, and the requirements and costs for
988+21 maintaining such equipment. Subject to prior approval, such
989+22 rules shall enable a recipient to temporarily acquire and use
990+23 alternative or substitute devices or equipment pending repairs
991+24 or replacements of any device or equipment previously
992+25 authorized for such recipient by the Department.
993+26 Notwithstanding any provision of Section 5-5f to the contrary,
994+
995+
996+
997+
998+
999+ SB0067 Enrolled - 28 - LRB103 04485 CPF 49491 b
1000+
1001+
1002+SB0067 Enrolled- 29 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 29 - LRB103 04485 CPF 49491 b
1003+ SB0067 Enrolled - 29 - LRB103 04485 CPF 49491 b
1004+1 the Department may, by rule, exempt certain replacement
1005+2 wheelchair parts from prior approval and, for wheelchairs,
1006+3 wheelchair parts, wheelchair accessories, and related seating
1007+4 and positioning items, determine the wholesale price by
1008+5 methods other than actual acquisition costs.
1009+6 The Department shall require, by rule, all providers of
1010+7 durable medical equipment to be accredited by an accreditation
1011+8 organization approved by the federal Centers for Medicare and
1012+9 Medicaid Services and recognized by the Department in order to
1013+10 bill the Department for providing durable medical equipment to
1014+11 recipients. No later than 15 months after the effective date
1015+12 of the rule adopted pursuant to this paragraph, all providers
1016+13 must meet the accreditation requirement.
1017+14 In order to promote environmental responsibility, meet the
1018+15 needs of recipients and enrollees, and achieve significant
1019+16 cost savings, the Department, or a managed care organization
1020+17 under contract with the Department, may provide recipients or
1021+18 managed care enrollees who have a prescription or Certificate
1022+19 of Medical Necessity access to refurbished durable medical
1023+20 equipment under this Section (excluding prosthetic and
1024+21 orthotic devices as defined in the Orthotics, Prosthetics, and
1025+22 Pedorthics Practice Act and complex rehabilitation technology
1026+23 products and associated services) through the State's
1027+24 assistive technology program's reutilization program, using
1028+25 staff with the Assistive Technology Professional (ATP)
1029+26 Certification if the refurbished durable medical equipment:
1030+
1031+
1032+
1033+
1034+
1035+ SB0067 Enrolled - 29 - LRB103 04485 CPF 49491 b
1036+
1037+
1038+SB0067 Enrolled- 30 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 30 - LRB103 04485 CPF 49491 b
1039+ SB0067 Enrolled - 30 - LRB103 04485 CPF 49491 b
1040+1 (i) is available; (ii) is less expensive, including shipping
1041+2 costs, than new durable medical equipment of the same type;
1042+3 (iii) is able to withstand at least 3 years of use; (iv) is
1043+4 cleaned, disinfected, sterilized, and safe in accordance with
1044+5 federal Food and Drug Administration regulations and guidance
1045+6 governing the reprocessing of medical devices in health care
1046+7 settings; and (v) equally meets the needs of the recipient or
1047+8 enrollee. The reutilization program shall confirm that the
1048+9 recipient or enrollee is not already in receipt of the same or
1049+10 similar equipment from another service provider, and that the
1050+11 refurbished durable medical equipment equally meets the needs
1051+12 of the recipient or enrollee. Nothing in this paragraph shall
1052+13 be construed to limit recipient or enrollee choice to obtain
1053+14 new durable medical equipment or place any additional prior
1054+15 authorization conditions on enrollees of managed care
1055+16 organizations.
1056+17 The Department shall execute, relative to the nursing home
1057+18 prescreening project, written inter-agency agreements with the
1058+19 Department of Human Services and the Department on Aging, to
1059+20 effect the following: (i) intake procedures and common
1060+21 eligibility criteria for those persons who are receiving
1061+22 non-institutional services; and (ii) the establishment and
1062+23 development of non-institutional services in areas of the
1063+24 State where they are not currently available or are
1064+25 undeveloped; and (iii) notwithstanding any other provision of
1065+26 law, subject to federal approval, on and after July 1, 2012, an
1066+
1067+
1068+
1069+
1070+
1071+ SB0067 Enrolled - 30 - LRB103 04485 CPF 49491 b
1072+
1073+
1074+SB0067 Enrolled- 31 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 31 - LRB103 04485 CPF 49491 b
1075+ SB0067 Enrolled - 31 - LRB103 04485 CPF 49491 b
1076+1 increase in the determination of need (DON) scores from 29 to
1077+2 37 for applicants for institutional and home and
1078+3 community-based long term care; if and only if federal
1079+4 approval is not granted, the Department may, in conjunction
1080+5 with other affected agencies, implement utilization controls
1081+6 or changes in benefit packages to effectuate a similar savings
1082+7 amount for this population; and (iv) no later than July 1,
1083+8 2013, minimum level of care eligibility criteria for
1084+9 institutional and home and community-based long term care; and
1085+10 (v) no later than October 1, 2013, establish procedures to
1086+11 permit long term care providers access to eligibility scores
1087+12 for individuals with an admission date who are seeking or
1088+13 receiving services from the long term care provider. In order
1089+14 to select the minimum level of care eligibility criteria, the
1090+15 Governor shall establish a workgroup that includes affected
1091+16 agency representatives and stakeholders representing the
1092+17 institutional and home and community-based long term care
1093+18 interests. This Section shall not restrict the Department from
1094+19 implementing lower level of care eligibility criteria for
1095+20 community-based services in circumstances where federal
1096+21 approval has been granted.
1097+22 The Illinois Department shall develop and operate, in
1098+23 cooperation with other State Departments and agencies and in
1099+24 compliance with applicable federal laws and regulations,
1100+25 appropriate and effective systems of health care evaluation
1101+26 and programs for monitoring of utilization of health care
1102+
1103+
1104+
1105+
1106+
1107+ SB0067 Enrolled - 31 - LRB103 04485 CPF 49491 b
1108+
1109+
1110+SB0067 Enrolled- 32 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 32 - LRB103 04485 CPF 49491 b
1111+ SB0067 Enrolled - 32 - LRB103 04485 CPF 49491 b
1112+1 services and facilities, as it affects persons eligible for
1113+2 medical assistance under this Code.
1114+3 The Illinois Department shall report annually to the
1115+4 General Assembly, no later than the second Friday in April of
1116+5 1979 and each year thereafter, in regard to:
1117+6 (a) actual statistics and trends in utilization of
1118+7 medical services by public aid recipients;
1119+8 (b) actual statistics and trends in the provision of
1120+9 the various medical services by medical vendors;
1121+10 (c) current rate structures and proposed changes in
1122+11 those rate structures for the various medical vendors; and
1123+12 (d) efforts at utilization review and control by the
1124+13 Illinois Department.
1125+14 The period covered by each report shall be the 3 years
1126+15 ending on the June 30 prior to the report. The report shall
1127+16 include suggested legislation for consideration by the General
1128+17 Assembly. The requirement for reporting to the General
1129+18 Assembly shall be satisfied by filing copies of the report as
1130+19 required by Section 3.1 of the General Assembly Organization
1131+20 Act, and filing such additional copies with the State
1132+21 Government Report Distribution Center for the General Assembly
1133+22 as is required under paragraph (t) of Section 7 of the State
1134+23 Library Act.
1135+24 Rulemaking authority to implement Public Act 95-1045, if
1136+25 any, is conditioned on the rules being adopted in accordance
1137+26 with all provisions of the Illinois Administrative Procedure
1138+
1139+
1140+
1141+
1142+
1143+ SB0067 Enrolled - 32 - LRB103 04485 CPF 49491 b
1144+
1145+
1146+SB0067 Enrolled- 33 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 33 - LRB103 04485 CPF 49491 b
1147+ SB0067 Enrolled - 33 - LRB103 04485 CPF 49491 b
1148+1 Act and all rules and procedures of the Joint Committee on
1149+2 Administrative Rules; any purported rule not so adopted, for
1150+3 whatever reason, is unauthorized.
1151+4 On and after July 1, 2012, the Department shall reduce any
1152+5 rate of reimbursement for services or other payments or alter
1153+6 any methodologies authorized by this Code to reduce any rate
1154+7 of reimbursement for services or other payments in accordance
1155+8 with Section 5-5e.
1156+9 Because kidney transplantation can be an appropriate,
1157+10 cost-effective alternative to renal dialysis when medically
1158+11 necessary and notwithstanding the provisions of Section 1-11
1159+12 of this Code, beginning October 1, 2014, the Department shall
1160+13 cover kidney transplantation for noncitizens with end-stage
1161+14 renal disease who are not eligible for comprehensive medical
1162+15 benefits, who meet the residency requirements of Section 5-3
1163+16 of this Code, and who would otherwise meet the financial
1164+17 requirements of the appropriate class of eligible persons
1165+18 under Section 5-2 of this Code. To qualify for coverage of
1166+19 kidney transplantation, such person must be receiving
1167+20 emergency renal dialysis services covered by the Department.
1168+21 Providers under this Section shall be prior approved and
1169+22 certified by the Department to perform kidney transplantation
1170+23 and the services under this Section shall be limited to
1171+24 services associated with kidney transplantation.
1172+25 Notwithstanding any other provision of this Code to the
1173+26 contrary, on or after July 1, 2015, all FDA approved forms of
1174+
1175+
1176+
1177+
1178+
1179+ SB0067 Enrolled - 33 - LRB103 04485 CPF 49491 b
1180+
1181+
1182+SB0067 Enrolled- 34 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 34 - LRB103 04485 CPF 49491 b
1183+ SB0067 Enrolled - 34 - LRB103 04485 CPF 49491 b
1184+1 medication assisted treatment prescribed for the treatment of
1185+2 alcohol dependence or treatment of opioid dependence shall be
1186+3 covered under both fee for service and managed care medical
1187+4 assistance programs for persons who are otherwise eligible for
1188+5 medical assistance under this Article and shall not be subject
1189+6 to any (1) utilization control, other than those established
1190+7 under the American Society of Addiction Medicine patient
1191+8 placement criteria, (2) prior authorization mandate, or (3)
1192+9 lifetime restriction limit mandate.
1193+10 On or after July 1, 2015, opioid antagonists prescribed
1194+11 for the treatment of an opioid overdose, including the
1195+12 medication product, administration devices, and any pharmacy
1196+13 fees or hospital fees related to the dispensing, distribution,
1197+14 and administration of the opioid antagonist, shall be covered
1198+15 under the medical assistance program for persons who are
1199+16 otherwise eligible for medical assistance under this Article.
1200+17 As used in this Section, "opioid antagonist" means a drug that
1201+18 binds to opioid receptors and blocks or inhibits the effect of
1202+19 opioids acting on those receptors, including, but not limited
1203+20 to, naloxone hydrochloride or any other similarly acting drug
1204+21 approved by the U.S. Food and Drug Administration. The
1205+22 Department shall not impose a copayment on the coverage
1206+23 provided for naloxone hydrochloride under the medical
1207+24 assistance program.
1208+25 Upon federal approval, the Department shall provide
1209+26 coverage and reimbursement for all drugs that are approved for
1210+
1211+
1212+
1213+
1214+
1215+ SB0067 Enrolled - 34 - LRB103 04485 CPF 49491 b
1216+
1217+
1218+SB0067 Enrolled- 35 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 35 - LRB103 04485 CPF 49491 b
1219+ SB0067 Enrolled - 35 - LRB103 04485 CPF 49491 b
1220+1 marketing by the federal Food and Drug Administration and that
1221+2 are recommended by the federal Public Health Service or the
1222+3 United States Centers for Disease Control and Prevention for
1223+4 pre-exposure prophylaxis and related pre-exposure prophylaxis
1224+5 services, including, but not limited to, HIV and sexually
1225+6 transmitted infection screening, treatment for sexually
1226+7 transmitted infections, medical monitoring, assorted labs, and
1227+8 counseling to reduce the likelihood of HIV infection among
1228+9 individuals who are not infected with HIV but who are at high
1229+10 risk of HIV infection.
1230+11 A federally qualified health center, as defined in Section
1231+12 1905(l)(2)(B) of the federal Social Security Act, shall be
1232+13 reimbursed by the Department in accordance with the federally
1233+14 qualified health center's encounter rate for services provided
1234+15 to medical assistance recipients that are performed by a
1235+16 dental hygienist, as defined under the Illinois Dental
1236+17 Practice Act, working under the general supervision of a
1237+18 dentist and employed by a federally qualified health center.
1238+19 Within 90 days after October 8, 2021 (the effective date
1239+20 of Public Act 102-665), the Department shall seek federal
1240+21 approval of a State Plan amendment to expand coverage for
1241+22 family planning services that includes presumptive eligibility
1242+23 to individuals whose income is at or below 208% of the federal
1243+24 poverty level. Coverage under this Section shall be effective
1244+25 beginning no later than December 1, 2022.
1245+26 Subject to approval by the federal Centers for Medicare
1246+
1247+
1248+
1249+
1250+
1251+ SB0067 Enrolled - 35 - LRB103 04485 CPF 49491 b
1252+
1253+
1254+SB0067 Enrolled- 36 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 36 - LRB103 04485 CPF 49491 b
1255+ SB0067 Enrolled - 36 - LRB103 04485 CPF 49491 b
1256+1 and Medicaid Services of a Title XIX State Plan amendment
1257+2 electing the Program of All-Inclusive Care for the Elderly
1258+3 (PACE) as a State Medicaid option, as provided for by Subtitle
1259+4 I (commencing with Section 4801) of Title IV of the Balanced
1260+5 Budget Act of 1997 (Public Law 105-33) and Part 460
1261+6 (commencing with Section 460.2) of Subchapter E of Title 42 of
1262+7 the Code of Federal Regulations, PACE program services shall
1263+8 become a covered benefit of the medical assistance program,
1264+9 subject to criteria established in accordance with all
1265+10 applicable laws.
1266+11 Notwithstanding any other provision of this Code,
1267+12 community-based pediatric palliative care from a trained
1268+13 interdisciplinary team shall be covered under the medical
1269+14 assistance program as provided in Section 15 of the Pediatric
1270+15 Palliative Care Act.
1271+16 Notwithstanding any other provision of this Code, within
1272+17 12 months after June 2, 2022 (the effective date of Public Act
1273+18 102-1037) this amendatory Act of the 102nd General Assembly
1274+19 and subject to federal approval, acupuncture services
1275+20 performed by an acupuncturist licensed under the Acupuncture
1276+21 Practice Act who is acting within the scope of his or her
1277+22 license shall be covered under the medical assistance program.
1278+23 The Department shall apply for any federal waiver or State
1279+24 Plan amendment, if required, to implement this paragraph. The
1280+25 Department may adopt any rules, including standards and
1281+26 criteria, necessary to implement this paragraph.
1282+
1283+
1284+
1285+
1286+
1287+ SB0067 Enrolled - 36 - LRB103 04485 CPF 49491 b
1288+
1289+
1290+SB0067 Enrolled- 37 -LRB103 04485 CPF 49491 b SB0067 Enrolled - 37 - LRB103 04485 CPF 49491 b
1291+ SB0067 Enrolled - 37 - LRB103 04485 CPF 49491 b
1292+
1293+
1294+
1295+
1296+
1297+ SB0067 Enrolled - 37 - LRB103 04485 CPF 49491 b