Illinois 2023-2024 Regular Session

Illinois Senate Bill SB0200 Compare Versions

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

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0200 Introduced 1/31/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2023, medically necessary orthodontic services may be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to use certain auto-qualifiers when determining whether an individual, who is otherwise eligible for medical assistance, is also eligible for coverage for a medically necessary orthodontic service. Provides that if the Department denies a claim for a medically necessary orthodontic service, the Department must, at a minimum, provide the following information to the provider of the orthodontic service: (i) the actual score of the orthodontic case; (ii) the name of the dentist or orthodontist who scored the orthodontic case; (iii) a detailed scoring sheet outlining the reasons for the score of the orthodontic case; and (iv) instructions on how to appeal the denied claim. LRB103 03520 KTG 48526 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0200 Introduced 1/31/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2023, medically necessary orthodontic services may be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to use certain auto-qualifiers when determining whether an individual, who is otherwise eligible for medical assistance, is also eligible for coverage for a medically necessary orthodontic service. Provides that if the Department denies a claim for a medically necessary orthodontic service, the Department must, at a minimum, provide the following information to the provider of the orthodontic service: (i) the actual score of the orthodontic case; (ii) the name of the dentist or orthodontist who scored the orthodontic case; (iii) a detailed scoring sheet outlining the reasons for the score of the orthodontic case; and (iv) instructions on how to appeal the denied claim. LRB103 03520 KTG 48526 b LRB103 03520 KTG 48526 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0200 Introduced 1/31/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new
4	4	305 ILCS 5/5-5 from Ch. 23, par. 5-5
5	5	305 ILCS 5/5-5.06f new
6	6	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2023, medically necessary orthodontic services may be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to use certain auto-qualifiers when determining whether an individual, who is otherwise eligible for medical assistance, is also eligible for coverage for a medically necessary orthodontic service. Provides that if the Department denies a claim for a medically necessary orthodontic service, the Department must, at a minimum, provide the following information to the provider of the orthodontic service: (i) the actual score of the orthodontic case; (ii) the name of the dentist or orthodontist who scored the orthodontic case; (iii) a detailed scoring sheet outlining the reasons for the score of the orthodontic case; and (iv) instructions on how to appeal the denied claim.
7	7	LRB103 03520 KTG 48526 b LRB103 03520 KTG 48526 b
8	8	LRB103 03520 KTG 48526 b
9	9	A BILL FOR
10	10	SB0200LRB103 03520 KTG 48526 b SB0200 LRB103 03520 KTG 48526 b
11	11	SB0200 LRB103 03520 KTG 48526 b
12	12	1 AN ACT concerning public aid.
13	13	2 Be it enacted by the People of the State of Illinois,
14	14	3 represented in the General Assembly:
15	15	4 Section 5. The Illinois Public Aid Code is amended by
16	16	5 changing Section 5-5 and by adding Section 5-5.06f as follows:
17	17	6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
18	18	7 (Text of Section after amendment by P.A. 102-1018 and P.A.
19	19	8 102-1038)
20	20	9 Sec. 5-5. Medical services. The Illinois Department, by
21	21	10 rule, shall determine the quantity and quality of and the rate
22	22	11 of reimbursement for the medical assistance for which payment
23	23	12 will be authorized, and the medical services to be provided,
24	24	13 which may include all or part of the following: (1) inpatient
25	25	14 hospital services; (2) outpatient hospital services; (3) other
26	26	15 laboratory and X-ray services; (4) skilled nursing home
27	27	16 services; (5) physicians' services whether furnished in the
28	28	17 office, the patient's home, a hospital, a skilled nursing
29	29	18 home, or elsewhere; (6) medical care, or any other type of
30	30	19 remedial care furnished by licensed practitioners; (7) home
31	31	20 health care services; (8) private duty nursing service; (9)
32	32	21 clinic services; (10) dental services, including prevention
33	33	22 and treatment of periodontal disease and dental caries disease
34	34	23 for pregnant individuals, provided by an individual licensed
35	35
36	36
37	37
38	38	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0200 Introduced 1/31/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED:
39	39	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5.06f new
40	40	305 ILCS 5/5-5 from Ch. 23, par. 5-5
41	41	305 ILCS 5/5-5.06f new
42	42	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2023, medically necessary orthodontic services may be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to use certain auto-qualifiers when determining whether an individual, who is otherwise eligible for medical assistance, is also eligible for coverage for a medically necessary orthodontic service. Provides that if the Department denies a claim for a medically necessary orthodontic service, the Department must, at a minimum, provide the following information to the provider of the orthodontic service: (i) the actual score of the orthodontic case; (ii) the name of the dentist or orthodontist who scored the orthodontic case; (iii) a detailed scoring sheet outlining the reasons for the score of the orthodontic case; and (iv) instructions on how to appeal the denied claim.
43	43	LRB103 03520 KTG 48526 b LRB103 03520 KTG 48526 b
44	44	LRB103 03520 KTG 48526 b
45	45	A BILL FOR
46	46
47	47
48	48
49	49
50	50
51	51	305 ILCS 5/5-5 from Ch. 23, par. 5-5
52	52	305 ILCS 5/5-5.06f new
53	53
54	54
55	55
56	56	LRB103 03520 KTG 48526 b
57	57
58	58
59	59
60	60
61	61
62	62
63	63
64	64
65	65
66	66	SB0200 LRB103 03520 KTG 48526 b
67	67
68	68
69	69	SB0200- 2 -LRB103 03520 KTG 48526 b SB0200 - 2 - LRB103 03520 KTG 48526 b
70	70	SB0200 - 2 - LRB103 03520 KTG 48526 b
71	71	1 to practice dentistry or dental surgery, and on and after July
72	72	2 1, 2023, medically necessary orthodontic services as provided
73	73	3 in Section 5-5.06f; for purposes of this item (10), "dental
74	74	4 services" means diagnostic, preventive, or corrective
75	75	5 procedures provided by or under the supervision of a dentist
76	76	6 in the practice of his or her profession; (11) physical
77	77	7 therapy and related services; (12) prescribed drugs, dentures,
78	78	8 and prosthetic devices; and eyeglasses prescribed by a
79	79	9 physician skilled in the diseases of the eye, or by an
80	80	10 optometrist, whichever the person may select; (13) other
81	81	11 diagnostic, screening, preventive, and rehabilitative
82	82	12 services, including to ensure that the individual's need for
83	83	13 intervention or treatment of mental disorders or substance use
84	84	14 disorders or co-occurring mental health and substance use
85	85	15 disorders is determined using a uniform screening, assessment,
86	86	16 and evaluation process inclusive of criteria, for children and
87	87	17 adults; for purposes of this item (13), a uniform screening,
88	88	18 assessment, and evaluation process refers to a process that
89	89	19 includes an appropriate evaluation and, as warranted, a
90	90	20 referral; "uniform" does not mean the use of a singular
91	91	21 instrument, tool, or process that all must utilize; (14)
92	92	22 transportation and such other expenses as may be necessary;
93	93	23 (15) medical treatment of sexual assault survivors, as defined
94	94	24 in Section 1a of the Sexual Assault Survivors Emergency
95	95	25 Treatment Act, for injuries sustained as a result of the
96	96	26 sexual assault, including examinations and laboratory tests to
97	97
98	98
99	99
100	100
101	101
102	102	SB0200 - 2 - LRB103 03520 KTG 48526 b
103	103
104	104
105	105	SB0200- 3 -LRB103 03520 KTG 48526 b SB0200 - 3 - LRB103 03520 KTG 48526 b
106	106	SB0200 - 3 - LRB103 03520 KTG 48526 b
107	107	1 discover evidence which may be used in criminal proceedings
108	108	2 arising from the sexual assault; (16) the diagnosis and
109	109	3 treatment of sickle cell anemia; (16.5) services performed by
110	110	4 a chiropractic physician licensed under the Medical Practice
111	111	5 Act of 1987 and acting within the scope of his or her license,
112	112	6 including, but not limited to, chiropractic manipulative
113	113	7 treatment; and (17) any other medical care, and any other type
114	114	8 of remedial care recognized under the laws of this State. The
115	115	9 term "any other type of remedial care" shall include nursing
116	116	10 care and nursing home service for persons who rely on
117	117	11 treatment by spiritual means alone through prayer for healing.
118	118	12 Notwithstanding any other provision of this Section, a
119	119	13 comprehensive tobacco use cessation program that includes
120	120	14 purchasing prescription drugs or prescription medical devices
121	121	15 approved by the Food and Drug Administration shall be covered
122	122	16 under the medical assistance program under this Article for
123	123	17 persons who are otherwise eligible for assistance under this
124	124	18 Article.
125	125	19 Notwithstanding any other provision of this Code,
126	126	20 reproductive health care that is otherwise legal in Illinois
127	127	21 shall be covered under the medical assistance program for
128	128	22 persons who are otherwise eligible for medical assistance
129	129	23 under this Article.
130	130	24 Notwithstanding any other provision of this Section, all
131	131	25 tobacco cessation medications approved by the United States
132	132	26 Food and Drug Administration and all individual and group
133	133
134	134
135	135
136	136
137	137
138	138	SB0200 - 3 - LRB103 03520 KTG 48526 b
139	139
140	140
141	141	SB0200- 4 -LRB103 03520 KTG 48526 b SB0200 - 4 - LRB103 03520 KTG 48526 b
142	142	SB0200 - 4 - LRB103 03520 KTG 48526 b
143	143	1 tobacco cessation counseling services and telephone-based
144	144	2 counseling services and tobacco cessation medications provided
145	145	3 through the Illinois Tobacco Quitline shall be covered under
146	146	4 the medical assistance program for persons who are otherwise
147	147	5 eligible for assistance under this Article. The Department
148	148	6 shall comply with all federal requirements necessary to obtain
149	149	7 federal financial participation, as specified in 42 CFR
150	150	8 433.15(b)(7), for telephone-based counseling services provided
151	151	9 through the Illinois Tobacco Quitline, including, but not
152	152	10 limited to: (i) entering into a memorandum of understanding or
153	153	11 interagency agreement with the Department of Public Health, as
154	154	12 administrator of the Illinois Tobacco Quitline; and (ii)
155	155	13 developing a cost allocation plan for Medicaid-allowable
156	156	14 Illinois Tobacco Quitline services in accordance with 45 CFR
157	157	15 95.507. The Department shall submit the memorandum of
158	158	16 understanding or interagency agreement, the cost allocation
159	159	17 plan, and all other necessary documentation to the Centers for
160	160	18 Medicare and Medicaid Services for review and approval.
161	161	19 Coverage under this paragraph shall be contingent upon federal
162	162	20 approval.
163	163	21 Notwithstanding any other provision of this Code, the
164	164	22 Illinois Department may not require, as a condition of payment
165	165	23 for any laboratory test authorized under this Article, that a
166	166	24 physician's handwritten signature appear on the laboratory
167	167	25 test order form. The Illinois Department may, however, impose
168	168	26 other appropriate requirements regarding laboratory test order
169	169
170	170
171	171
172	172
173	173
174	174	SB0200 - 4 - LRB103 03520 KTG 48526 b
175	175
176	176
177	177	SB0200- 5 -LRB103 03520 KTG 48526 b SB0200 - 5 - LRB103 03520 KTG 48526 b
178	178	SB0200 - 5 - LRB103 03520 KTG 48526 b
179	179	1 documentation.
180	180	2 Upon receipt of federal approval of an amendment to the
181	181	3 Illinois Title XIX State Plan for this purpose, the Department
182	182	4 shall authorize the Chicago Public Schools (CPS) to procure a
183	183	5 vendor or vendors to manufacture eyeglasses for individuals
184	184	6 enrolled in a school within the CPS system. CPS shall ensure
185	185	7 that its vendor or vendors are enrolled as providers in the
186	186	8 medical assistance program and in any capitated Medicaid
187	187	9 managed care entity (MCE) serving individuals enrolled in a
188	188	10 school within the CPS system. Under any contract procured
189	189	11 under this provision, the vendor or vendors must serve only
190	190	12 individuals enrolled in a school within the CPS system. Claims
191	191	13 for services provided by CPS's vendor or vendors to recipients
192	192	14 of benefits in the medical assistance program under this Code,
193	193	15 the Children's Health Insurance Program, or the Covering ALL
194	194	16 KIDS Health Insurance Program shall be submitted to the
195	195	17 Department or the MCE in which the individual is enrolled for
196	196	18 payment and shall be reimbursed at the Department's or the
197	197	19 MCE's established rates or rate methodologies for eyeglasses.
198	198	20 On and after July 1, 2012, the Department of Healthcare
199	199	21 and Family Services may provide the following services to
200	200	22 persons eligible for assistance under this Article who are
201	201	23 participating in education, training or employment programs
202	202	24 operated by the Department of Human Services as successor to
203	203	25 the Department of Public Aid:
204	204	26 (1) dental services provided by or under the
205	205
206	206
207	207
208	208
209	209
210	210	SB0200 - 5 - LRB103 03520 KTG 48526 b
211	211
212	212
213	213	SB0200- 6 -LRB103 03520 KTG 48526 b SB0200 - 6 - LRB103 03520 KTG 48526 b
214	214	SB0200 - 6 - LRB103 03520 KTG 48526 b
215	215	1 supervision of a dentist; and
216	216	2 (2) eyeglasses prescribed by a physician skilled in
217	217	3 the diseases of the eye, or by an optometrist, whichever
218	218	4 the person may select.
219	219	5 On and after July 1, 2018, the Department of Healthcare
220	220	6 and Family Services shall provide dental services to any adult
221	221	7 who is otherwise eligible for assistance under the medical
222	222	8 assistance program. As used in this paragraph, "dental
223	223	9 services" means diagnostic, preventative, restorative, or
224	224	10 corrective procedures, including procedures and services for
225	225	11 the prevention and treatment of periodontal disease and dental
226	226	12 caries disease, provided by an individual who is licensed to
227	227	13 practice dentistry or dental surgery or who is under the
228	228	14 supervision of a dentist in the practice of his or her
229	229	15 profession.
230	230	16 On and after July 1, 2018, targeted dental services, as
231	231	17 set forth in Exhibit D of the Consent Decree entered by the
232	232	18 United States District Court for the Northern District of
233	233	19 Illinois, Eastern Division, in the matter of Memisovski v.
234	234	20 Maram, Case No. 92 C 1982, that are provided to adults under
235	235	21 the medical assistance program shall be established at no less
236	236	22 than the rates set forth in the "New Rate" column in Exhibit D
237	237	23 of the Consent Decree for targeted dental services that are
238	238	24 provided to persons under the age of 18 under the medical
239	239	25 assistance program.
240	240	26 Notwithstanding any other provision of this Code and
241	241
242	242
243	243
244	244
245	245
246	246	SB0200 - 6 - LRB103 03520 KTG 48526 b
247	247
248	248
249	249	SB0200- 7 -LRB103 03520 KTG 48526 b SB0200 - 7 - LRB103 03520 KTG 48526 b
250	250	SB0200 - 7 - LRB103 03520 KTG 48526 b
251	251	1 subject to federal approval, the Department may adopt rules to
252	252	2 allow a dentist who is volunteering his or her service at no
253	253	3 cost to render dental services through an enrolled
254	254	4 not-for-profit health clinic without the dentist personally
255	255	5 enrolling as a participating provider in the medical
256	256	6 assistance program. A not-for-profit health clinic shall
257	257	7 include a public health clinic or Federally Qualified Health
258	258	8 Center or other enrolled provider, as determined by the
259	259	9 Department, through which dental services covered under this
260	260	10 Section are performed. The Department shall establish a
261	261	11 process for payment of claims for reimbursement for covered
262	262	12 dental services rendered under this provision.
263	263	13 On and after January 1, 2022, the Department of Healthcare
264	264	14 and Family Services shall administer and regulate a
265	265	15 school-based dental program that allows for the out-of-office
266	266	16 delivery of preventative dental services in a school setting
267	267	17 to children under 19 years of age. The Department shall
268	268	18 establish, by rule, guidelines for participation by providers
269	269	19 and set requirements for follow-up referral care based on the
270	270	20 requirements established in the Dental Office Reference Manual
271	271	21 published by the Department that establishes the requirements
272	272	22 for dentists participating in the All Kids Dental School
273	273	23 Program. Every effort shall be made by the Department when
274	274	24 developing the program requirements to consider the different
275	275	25 geographic differences of both urban and rural areas of the
276	276	26 State for initial treatment and necessary follow-up care. No
277	277
278	278
279	279
280	280
281	281
282	282	SB0200 - 7 - LRB103 03520 KTG 48526 b
283	283
284	284
285	285	SB0200- 8 -LRB103 03520 KTG 48526 b SB0200 - 8 - LRB103 03520 KTG 48526 b
286	286	SB0200 - 8 - LRB103 03520 KTG 48526 b
287	287	1 provider shall be charged a fee by any unit of local government
288	288	2 to participate in the school-based dental program administered
289	289	3 by the Department. Nothing in this paragraph shall be
290	290	4 construed to limit or preempt a home rule unit's or school
291	291	5 district's authority to establish, change, or administer a
292	292	6 school-based dental program in addition to, or independent of,
293	293	7 the school-based dental program administered by the
294	294	8 Department.
295	295	9 The Illinois Department, by rule, may distinguish and
296	296	10 classify the medical services to be provided only in
297	297	11 accordance with the classes of persons designated in Section
298	298	12 5-2.
299	299	13 The Department of Healthcare and Family Services must
300	300	14 provide coverage and reimbursement for amino acid-based
301	301	15 elemental formulas, regardless of delivery method, for the
302	302	16 diagnosis and treatment of (i) eosinophilic disorders and (ii)
303	303	17 short bowel syndrome when the prescribing physician has issued
304	304	18 a written order stating that the amino acid-based elemental
305	305	19 formula is medically necessary.
306	306	20 The Illinois Department shall authorize the provision of,
307	307	21 and shall authorize payment for, screening by low-dose
308	308	22 mammography for the presence of occult breast cancer for
309	309	23 individuals 35 years of age or older who are eligible for
310	310	24 medical assistance under this Article, as follows:
311	311	25 (A) A baseline mammogram for individuals 35 to 39
312	312	26 years of age.
313	313
314	314
315	315
316	316
317	317
318	318	SB0200 - 8 - LRB103 03520 KTG 48526 b
319	319
320	320
321	321	SB0200- 9 -LRB103 03520 KTG 48526 b SB0200 - 9 - LRB103 03520 KTG 48526 b
322	322	SB0200 - 9 - LRB103 03520 KTG 48526 b
323	323	1 (B) An annual mammogram for individuals 40 years of
324	324	2 age or older.
325	325	3 (C) A mammogram at the age and intervals considered
326	326	4 medically necessary by the individual's health care
327	327	5 provider for individuals under 40 years of age and having
328	328	6 a family history of breast cancer, prior personal history
329	329	7 of breast cancer, positive genetic testing, or other risk
330	330	8 factors.
331	331	9 (D) A comprehensive ultrasound screening and MRI of an
332	332	10 entire breast or breasts if a mammogram demonstrates
333	333	11 heterogeneous or dense breast tissue or when medically
334	334	12 necessary as determined by a physician licensed to
335	335	13 practice medicine in all of its branches.
336	336	14 (E) A screening MRI when medically necessary, as
337	337	15 determined by a physician licensed to practice medicine in
338	338	16 all of its branches.
339	339	17 (F) A diagnostic mammogram when medically necessary,
340	340	18 as determined by a physician licensed to practice medicine
341	341	19 in all its branches, advanced practice registered nurse,
342	342	20 or physician assistant.
343	343	21 The Department shall not impose a deductible, coinsurance,
344	344	22 copayment, or any other cost-sharing requirement on the
345	345	23 coverage provided under this paragraph; except that this
346	346	24 sentence does not apply to coverage of diagnostic mammograms
347	347	25 to the extent such coverage would disqualify a high-deductible
348	348	26 health plan from eligibility for a health savings account
349	349
350	350
351	351
352	352
353	353
354	354	SB0200 - 9 - LRB103 03520 KTG 48526 b
355	355
356	356
357	357	SB0200- 10 -LRB103 03520 KTG 48526 b SB0200 - 10 - LRB103 03520 KTG 48526 b
358	358	SB0200 - 10 - LRB103 03520 KTG 48526 b
359	359	1 pursuant to Section 223 of the Internal Revenue Code (26
360	360	2 U.S.C. 223).
361	361	3 All screenings shall include a physical breast exam,
362	362	4 instruction on self-examination and information regarding the
363	363	5 frequency of self-examination and its value as a preventative
364	364	6 tool.
365	365	7 For purposes of this Section:
366	366	8 "Diagnostic mammogram" means a mammogram obtained using
367	367	9 diagnostic mammography.
368	368	10 "Diagnostic mammography" means a method of screening that
369	369	11 is designed to evaluate an abnormality in a breast, including
370	370	12 an abnormality seen or suspected on a screening mammogram or a
371	371	13 subjective or objective abnormality otherwise detected in the
372	372	14 breast.
373	373	15 "Low-dose mammography" means the x-ray examination of the
374	374	16 breast using equipment dedicated specifically for mammography,
375	375	17 including the x-ray tube, filter, compression device, and
376	376	18 image receptor, with an average radiation exposure delivery of
377	377	19 less than one rad per breast for 2 views of an average size
378	378	20 breast. The term also includes digital mammography and
379	379	21 includes breast tomosynthesis.
380	380	22 "Breast tomosynthesis" means a radiologic procedure that
381	381	23 involves the acquisition of projection images over the
382	382	24 stationary breast to produce cross-sectional digital
383	383	25 three-dimensional images of the breast.
384	384	26 If, at any time, the Secretary of the United States
385	385
386	386
387	387
388	388
389	389
390	390	SB0200 - 10 - LRB103 03520 KTG 48526 b
391	391
392	392
393	393	SB0200- 11 -LRB103 03520 KTG 48526 b SB0200 - 11 - LRB103 03520 KTG 48526 b
394	394	SB0200 - 11 - LRB103 03520 KTG 48526 b
395	395	1 Department of Health and Human Services, or its successor
396	396	2 agency, promulgates rules or regulations to be published in
397	397	3 the Federal Register or publishes a comment in the Federal
398	398	4 Register or issues an opinion, guidance, or other action that
399	399	5 would require the State, pursuant to any provision of the
400	400	6 Patient Protection and Affordable Care Act (Public Law
401	401	7 111-148), including, but not limited to, 42 U.S.C.
402	402	8 18031(d)(3)(B) or any successor provision, to defray the cost
403	403	9 of any coverage for breast tomosynthesis outlined in this
404	404	10 paragraph, then the requirement that an insurer cover breast
405	405	11 tomosynthesis is inoperative other than any such coverage
406	406	12 authorized under Section 1902 of the Social Security Act, 42
407	407	13 U.S.C. 1396a, and the State shall not assume any obligation
408	408	14 for the cost of coverage for breast tomosynthesis set forth in
409	409	15 this paragraph.
410	410	16 On and after January 1, 2016, the Department shall ensure
411	411	17 that all networks of care for adult clients of the Department
412	412	18 include access to at least one breast imaging Center of
413	413	19 Imaging Excellence as certified by the American College of
414	414	20 Radiology.
415	415	21 On and after January 1, 2012, providers participating in a
416	416	22 quality improvement program approved by the Department shall
417	417	23 be reimbursed for screening and diagnostic mammography at the
418	418	24 same rate as the Medicare program's rates, including the
419	419	25 increased reimbursement for digital mammography and, after
420	420	26 January 1, 2023 (the effective date of Public Act 102-1018)
421	421
422	422
423	423
424	424
425	425
426	426	SB0200 - 11 - LRB103 03520 KTG 48526 b
427	427
428	428
429	429	SB0200- 12 -LRB103 03520 KTG 48526 b SB0200 - 12 - LRB103 03520 KTG 48526 b
430	430	SB0200 - 12 - LRB103 03520 KTG 48526 b
431	431	1 this amendatory Act of the 102nd General Assembly, breast
432	432	2 tomosynthesis.
433	433	3 The Department shall convene an expert panel including
434	434	4 representatives of hospitals, free-standing mammography
435	435	5 facilities, and doctors, including radiologists, to establish
436	436	6 quality standards for mammography.
437	437	7 On and after January 1, 2017, providers participating in a
438	438	8 breast cancer treatment quality improvement program approved
439	439	9 by the Department shall be reimbursed for breast cancer
440	440	10 treatment at a rate that is no lower than 95% of the Medicare
441	441	11 program's rates for the data elements included in the breast
442	442	12 cancer treatment quality program.
443	443	13 The Department shall convene an expert panel, including
444	444	14 representatives of hospitals, free-standing breast cancer
445	445	15 treatment centers, breast cancer quality organizations, and
446	446	16 doctors, including breast surgeons, reconstructive breast
447	447	17 surgeons, oncologists, and primary care providers to establish
448	448	18 quality standards for breast cancer treatment.
449	449	19 Subject to federal approval, the Department shall
450	450	20 establish a rate methodology for mammography at federally
451	451	21 qualified health centers and other encounter-rate clinics.
452	452	22 These clinics or centers may also collaborate with other
453	453	23 hospital-based mammography facilities. By January 1, 2016, the
454	454	24 Department shall report to the General Assembly on the status
455	455	25 of the provision set forth in this paragraph.
456	456	26 The Department shall establish a methodology to remind
457	457
458	458
459	459
460	460
461	461
462	462	SB0200 - 12 - LRB103 03520 KTG 48526 b
463	463
464	464
465	465	SB0200- 13 -LRB103 03520 KTG 48526 b SB0200 - 13 - LRB103 03520 KTG 48526 b
466	466	SB0200 - 13 - LRB103 03520 KTG 48526 b
467	467	1 individuals who are age-appropriate for screening mammography,
468	468	2 but who have not received a mammogram within the previous 18
469	469	3 months, of the importance and benefit of screening
470	470	4 mammography. The Department shall work with experts in breast
471	471	5 cancer outreach and patient navigation to optimize these
472	472	6 reminders and shall establish a methodology for evaluating
473	473	7 their effectiveness and modifying the methodology based on the
474	474	8 evaluation.
475	475	9 The Department shall establish a performance goal for
476	476	10 primary care providers with respect to their female patients
477	477	11 over age 40 receiving an annual mammogram. This performance
478	478	12 goal shall be used to provide additional reimbursement in the
479	479	13 form of a quality performance bonus to primary care providers
480	480	14 who meet that goal.
481	481	15 The Department shall devise a means of case-managing or
482	482	16 patient navigation for beneficiaries diagnosed with breast
483	483	17 cancer. This program shall initially operate as a pilot
484	484	18 program in areas of the State with the highest incidence of
485	485	19 mortality related to breast cancer. At least one pilot program
486	486	20 site shall be in the metropolitan Chicago area and at least one
487	487	21 site shall be outside the metropolitan Chicago area. On or
488	488	22 after July 1, 2016, the pilot program shall be expanded to
489	489	23 include one site in western Illinois, one site in southern
490	490	24 Illinois, one site in central Illinois, and 4 sites within
491	491	25 metropolitan Chicago. An evaluation of the pilot program shall
492	492	26 be carried out measuring health outcomes and cost of care for
493	493
494	494
495	495
496	496
497	497
498	498	SB0200 - 13 - LRB103 03520 KTG 48526 b
499	499
500	500
501	501	SB0200- 14 -LRB103 03520 KTG 48526 b SB0200 - 14 - LRB103 03520 KTG 48526 b
502	502	SB0200 - 14 - LRB103 03520 KTG 48526 b
503	503	1 those served by the pilot program compared to similarly
504	504	2 situated patients who are not served by the pilot program.
505	505	3 The Department shall require all networks of care to
506	506	4 develop a means either internally or by contract with experts
507	507	5 in navigation and community outreach to navigate cancer
508	508	6 patients to comprehensive care in a timely fashion. The
509	509	7 Department shall require all networks of care to include
510	510	8 access for patients diagnosed with cancer to at least one
511	511	9 academic commission on cancer-accredited cancer program as an
512	512	10 in-network covered benefit.
513	513	11 The Department shall provide coverage and reimbursement
514	514	12 for a human papillomavirus (HPV) vaccine that is approved for
515	515	13 marketing by the federal Food and Drug Administration for all
516	516	14 persons between the ages of 9 and 45 and persons of the age of
517	517	15 46 and above who have been diagnosed with cervical dysplasia
518	518	16 with a high risk of recurrence or progression. The Department
519	519	17 shall disallow any preauthorization requirements for the
520	520	18 administration of the human papillomavirus (HPV) vaccine.
521	521	19 On or after July 1, 2022, individuals who are otherwise
522	522	20 eligible for medical assistance under this Article shall
523	523	21 receive coverage for perinatal depression screenings for the
524	524	22 12-month period beginning on the last day of their pregnancy.
525	525	23 Medical assistance coverage under this paragraph shall be
526	526	24 conditioned on the use of a screening instrument approved by
527	527	25 the Department.
528	528	26 Any medical or health care provider shall immediately
529	529
530	530
531	531
532	532
533	533
534	534	SB0200 - 14 - LRB103 03520 KTG 48526 b
535	535
536	536
537	537	SB0200- 15 -LRB103 03520 KTG 48526 b SB0200 - 15 - LRB103 03520 KTG 48526 b
538	538	SB0200 - 15 - LRB103 03520 KTG 48526 b
539	539	1 recommend, to any pregnant individual who is being provided
540	540	2 prenatal services and is suspected of having a substance use
541	541	3 disorder as defined in the Substance Use Disorder Act,
542	542	4 referral to a local substance use disorder treatment program
543	543	5 licensed by the Department of Human Services or to a licensed
544	544	6 hospital which provides substance abuse treatment services.
545	545	7 The Department of Healthcare and Family Services shall assure
546	546	8 coverage for the cost of treatment of the drug abuse or
547	547	9 addiction for pregnant recipients in accordance with the
548	548	10 Illinois Medicaid Program in conjunction with the Department
549	549	11 of Human Services.
550	550	12 All medical providers providing medical assistance to
551	551	13 pregnant individuals under this Code shall receive information
552	552	14 from the Department on the availability of services under any
553	553	15 program providing case management services for addicted
554	554	16 individuals, including information on appropriate referrals
555	555	17 for other social services that may be needed by addicted
556	556	18 individuals in addition to treatment for addiction.
557	557	19 The Illinois Department, in cooperation with the
558	558	20 Departments of Human Services (as successor to the Department
559	559	21 of Alcoholism and Substance Abuse) and Public Health, through
560	560	22 a public awareness campaign, may provide information
561	561	23 concerning treatment for alcoholism and drug abuse and
562	562	24 addiction, prenatal health care, and other pertinent programs
563	563	25 directed at reducing the number of drug-affected infants born
564	564	26 to recipients of medical assistance.
565	565
566	566
567	567
568	568
569	569
570	570	SB0200 - 15 - LRB103 03520 KTG 48526 b
571	571
572	572
573	573	SB0200- 16 -LRB103 03520 KTG 48526 b SB0200 - 16 - LRB103 03520 KTG 48526 b
574	574	SB0200 - 16 - LRB103 03520 KTG 48526 b
575	575	1 Neither the Department of Healthcare and Family Services
576	576	2 nor the Department of Human Services shall sanction the
577	577	3 recipient solely on the basis of the recipient's substance
578	578	4 abuse.
579	579	5 The Illinois Department shall establish such regulations
580	580	6 governing the dispensing of health services under this Article
581	581	7 as it shall deem appropriate. The Department should seek the
582	582	8 advice of formal professional advisory committees appointed by
583	583	9 the Director of the Illinois Department for the purpose of
584	584	10 providing regular advice on policy and administrative matters,
585	585	11 information dissemination and educational activities for
586	586	12 medical and health care providers, and consistency in
587	587	13 procedures to the Illinois Department.
588	588	14 The Illinois Department may develop and contract with
589	589	15 Partnerships of medical providers to arrange medical services
590	590	16 for persons eligible under Section 5-2 of this Code.
591	591	17 Implementation of this Section may be by demonstration
592	592	18 projects in certain geographic areas. The Partnership shall be
593	593	19 represented by a sponsor organization. The Department, by
594	594	20 rule, shall develop qualifications for sponsors of
595	595	21 Partnerships. Nothing in this Section shall be construed to
596	596	22 require that the sponsor organization be a medical
597	597	23 organization.
598	598	24 The sponsor must negotiate formal written contracts with
599	599	25 medical providers for physician services, inpatient and
600	600	26 outpatient hospital care, home health services, treatment for
601	601
602	602
603	603
604	604
605	605
606	606	SB0200 - 16 - LRB103 03520 KTG 48526 b
607	607
608	608
609	609	SB0200- 17 -LRB103 03520 KTG 48526 b SB0200 - 17 - LRB103 03520 KTG 48526 b
610	610	SB0200 - 17 - LRB103 03520 KTG 48526 b
611	611	1 alcoholism and substance abuse, and other services determined
612	612	2 necessary by the Illinois Department by rule for delivery by
613	613	3 Partnerships. Physician services must include prenatal and
614	614	4 obstetrical care. The Illinois Department shall reimburse
615	615	5 medical services delivered by Partnership providers to clients
616	616	6 in target areas according to provisions of this Article and
617	617	7 the Illinois Health Finance Reform Act, except that:
618	618	8 (1) Physicians participating in a Partnership and
619	619	9 providing certain services, which shall be determined by
620	620	10 the Illinois Department, to persons in areas covered by
621	621	11 the Partnership may receive an additional surcharge for
622	622	12 such services.
623	623	13 (2) The Department may elect to consider and negotiate
624	624	14 financial incentives to encourage the development of
625	625	15 Partnerships and the efficient delivery of medical care.
626	626	16 (3) Persons receiving medical services through
627	627	17 Partnerships may receive medical and case management
628	628	18 services above the level usually offered through the
629	629	19 medical assistance program.
630	630	20 Medical providers shall be required to meet certain
631	631	21 qualifications to participate in Partnerships to ensure the
632	632	22 delivery of high quality medical services. These
633	633	23 qualifications shall be determined by rule of the Illinois
634	634	24 Department and may be higher than qualifications for
635	635	25 participation in the medical assistance program. Partnership
636	636	26 sponsors may prescribe reasonable additional qualifications
637	637
638	638
639	639
640	640
641	641
642	642	SB0200 - 17 - LRB103 03520 KTG 48526 b
643	643
644	644
645	645	SB0200- 18 -LRB103 03520 KTG 48526 b SB0200 - 18 - LRB103 03520 KTG 48526 b
646	646	SB0200 - 18 - LRB103 03520 KTG 48526 b
647	647	1 for participation by medical providers, only with the prior
648	648	2 written approval of the Illinois Department.
649	649	3 Nothing in this Section shall limit the free choice of
650	650	4 practitioners, hospitals, and other providers of medical
651	651	5 services by clients. In order to ensure patient freedom of
652	652	6 choice, the Illinois Department shall immediately promulgate
653	653	7 all rules and take all other necessary actions so that
654	654	8 provided services may be accessed from therapeutically
655	655	9 certified optometrists to the full extent of the Illinois
656	656	10 Optometric Practice Act of 1987 without discriminating between
657	657	11 service providers.
658	658	12 The Department shall apply for a waiver from the United
659	659	13 States Health Care Financing Administration to allow for the
660	660	14 implementation of Partnerships under this Section.
661	661	15 The Illinois Department shall require health care
662	662	16 providers to maintain records that document the medical care
663	663	17 and services provided to recipients of Medical Assistance
664	664	18 under this Article. Such records must be retained for a period
665	665	19 of not less than 6 years from the date of service or as
666	666	20 provided by applicable State law, whichever period is longer,
667	667	21 except that if an audit is initiated within the required
668	668	22 retention period then the records must be retained until the
669	669	23 audit is completed and every exception is resolved. The
670	670	24 Illinois Department shall require health care providers to
671	671	25 make available, when authorized by the patient, in writing,
672	672	26 the medical records in a timely fashion to other health care
673	673
674	674
675	675
676	676
677	677
678	678	SB0200 - 18 - LRB103 03520 KTG 48526 b
679	679
680	680
681	681	SB0200- 19 -LRB103 03520 KTG 48526 b SB0200 - 19 - LRB103 03520 KTG 48526 b
682	682	SB0200 - 19 - LRB103 03520 KTG 48526 b
683	683	1 providers who are treating or serving persons eligible for
684	684	2 Medical Assistance under this Article. All dispensers of
685	685	3 medical services shall be required to maintain and retain
686	686	4 business and professional records sufficient to fully and
687	687	5 accurately document the nature, scope, details and receipt of
688	688	6 the health care provided to persons eligible for medical
689	689	7 assistance under this Code, in accordance with regulations
690	690	8 promulgated by the Illinois Department. The rules and
691	691	9 regulations shall require that proof of the receipt of
692	692	10 prescription drugs, dentures, prosthetic devices and
693	693	11 eyeglasses by eligible persons under this Section accompany
694	694	12 each claim for reimbursement submitted by the dispenser of
695	695	13 such medical services. No such claims for reimbursement shall
696	696	14 be approved for payment by the Illinois Department without
697	697	15 such proof of receipt, unless the Illinois Department shall
698	698	16 have put into effect and shall be operating a system of
699	699	17 post-payment audit and review which shall, on a sampling
700	700	18 basis, be deemed adequate by the Illinois Department to assure
701	701	19 that such drugs, dentures, prosthetic devices and eyeglasses
702	702	20 for which payment is being made are actually being received by
703	703	21 eligible recipients. Within 90 days after September 16, 1984
704	704	22 (the effective date of Public Act 83-1439), the Illinois
705	705	23 Department shall establish a current list of acquisition costs
706	706	24 for all prosthetic devices and any other items recognized as
707	707	25 medical equipment and supplies reimbursable under this Article
708	708	26 and shall update such list on a quarterly basis, except that
709	709
710	710
711	711
712	712
713	713
714	714	SB0200 - 19 - LRB103 03520 KTG 48526 b
715	715
716	716
717	717	SB0200- 20 -LRB103 03520 KTG 48526 b SB0200 - 20 - LRB103 03520 KTG 48526 b
718	718	SB0200 - 20 - LRB103 03520 KTG 48526 b
719	719	1 the acquisition costs of all prescription drugs shall be
720	720	2 updated no less frequently than every 30 days as required by
721	721	3 Section 5-5.12.
722	722	4 Notwithstanding any other law to the contrary, the
723	723	5 Illinois Department shall, within 365 days after July 22, 2013
724	724	6 (the effective date of Public Act 98-104), establish
725	725	7 procedures to permit skilled care facilities licensed under
726	726	8 the Nursing Home Care Act to submit monthly billing claims for
727	727	9 reimbursement purposes. Following development of these
728	728	10 procedures, the Department shall, by July 1, 2016, test the
729	729	11 viability of the new system and implement any necessary
730	730	12 operational or structural changes to its information
731	731	13 technology platforms in order to allow for the direct
732	732	14 acceptance and payment of nursing home claims.
733	733	15 Notwithstanding any other law to the contrary, the
734	734	16 Illinois Department shall, within 365 days after August 15,
735	735	17 2014 (the effective date of Public Act 98-963), establish
736	736	18 procedures to permit ID/DD facilities licensed under the ID/DD
737	737	19 Community Care Act and MC/DD facilities licensed under the
738	738	20 MC/DD Act to submit monthly billing claims for reimbursement
739	739	21 purposes. Following development of these procedures, the
740	740	22 Department shall have an additional 365 days to test the
741	741	23 viability of the new system and to ensure that any necessary
742	742	24 operational or structural changes to its information
743	743	25 technology platforms are implemented.
744	744	26 The Illinois Department shall require all dispensers of
745	745
746	746
747	747
748	748
749	749
750	750	SB0200 - 20 - LRB103 03520 KTG 48526 b
751	751
752	752
753	753	SB0200- 21 -LRB103 03520 KTG 48526 b SB0200 - 21 - LRB103 03520 KTG 48526 b
754	754	SB0200 - 21 - LRB103 03520 KTG 48526 b
755	755	1 medical services, other than an individual practitioner or
756	756	2 group of practitioners, desiring to participate in the Medical
757	757	3 Assistance program established under this Article to disclose
758	758	4 all financial, beneficial, ownership, equity, surety or other
759	759	5 interests in any and all firms, corporations, partnerships,
760	760	6 associations, business enterprises, joint ventures, agencies,
761	761	7 institutions or other legal entities providing any form of
762	762	8 health care services in this State under this Article.
763	763	9 The Illinois Department may require that all dispensers of
764	764	10 medical services desiring to participate in the medical
765	765	11 assistance program established under this Article disclose,
766	766	12 under such terms and conditions as the Illinois Department may
767	767	13 by rule establish, all inquiries from clients and attorneys
768	768	14 regarding medical bills paid by the Illinois Department, which
769	769	15 inquiries could indicate potential existence of claims or
770	770	16 liens for the Illinois Department.
771	771	17 Enrollment of a vendor shall be subject to a provisional
772	772	18 period and shall be conditional for one year. During the
773	773	19 period of conditional enrollment, the Department may terminate
774	774	20 the vendor's eligibility to participate in, or may disenroll
775	775	21 the vendor from, the medical assistance program without cause.
776	776	22 Unless otherwise specified, such termination of eligibility or
777	777	23 disenrollment is not subject to the Department's hearing
778	778	24 process. However, a disenrolled vendor may reapply without
779	779	25 penalty.
780	780	26 The Department has the discretion to limit the conditional
781	781
782	782
783	783
784	784
785	785
786	786	SB0200 - 21 - LRB103 03520 KTG 48526 b
787	787
788	788
789	789	SB0200- 22 -LRB103 03520 KTG 48526 b SB0200 - 22 - LRB103 03520 KTG 48526 b
790	790	SB0200 - 22 - LRB103 03520 KTG 48526 b
791	791	1 enrollment period for vendors based upon category of risk of
792	792	2 the vendor.
793	793	3 Prior to enrollment and during the conditional enrollment
794	794	4 period in the medical assistance program, all vendors shall be
795	795	5 subject to enhanced oversight, screening, and review based on
796	796	6 the risk of fraud, waste, and abuse that is posed by the
797	797	7 category of risk of the vendor. The Illinois Department shall
798	798	8 establish the procedures for oversight, screening, and review,
799	799	9 which may include, but need not be limited to: criminal and
800	800	10 financial background checks; fingerprinting; license,
801	801	11 certification, and authorization verifications; unscheduled or
802	802	12 unannounced site visits; database checks; prepayment audit
803	803	13 reviews; audits; payment caps; payment suspensions; and other
804	804	14 screening as required by federal or State law.
805	805	15 The Department shall define or specify the following: (i)
806	806	16 by provider notice, the "category of risk of the vendor" for
807	807	17 each type of vendor, which shall take into account the level of
808	808	18 screening applicable to a particular category of vendor under
809	809	19 federal law and regulations; (ii) by rule or provider notice,
810	810	20 the maximum length of the conditional enrollment period for
811	811	21 each category of risk of the vendor; and (iii) by rule, the
812	812	22 hearing rights, if any, afforded to a vendor in each category
813	813	23 of risk of the vendor that is terminated or disenrolled during
814	814	24 the conditional enrollment period.
815	815	25 To be eligible for payment consideration, a vendor's
816	816	26 payment claim or bill, either as an initial claim or as a
817	817
818	818
819	819
820	820
821	821
822	822	SB0200 - 22 - LRB103 03520 KTG 48526 b
823	823
824	824
825	825	SB0200- 23 -LRB103 03520 KTG 48526 b SB0200 - 23 - LRB103 03520 KTG 48526 b
826	826	SB0200 - 23 - LRB103 03520 KTG 48526 b
827	827	1 resubmitted claim following prior rejection, must be received
828	828	2 by the Illinois Department, or its fiscal intermediary, no
829	829	3 later than 180 days after the latest date on the claim on which
830	830	4 medical goods or services were provided, with the following
831	831	5 exceptions:
832	832	6 (1) In the case of a provider whose enrollment is in
833	833	7 process by the Illinois Department, the 180-day period
834	834	8 shall not begin until the date on the written notice from
835	835	9 the Illinois Department that the provider enrollment is
836	836	10 complete.
837	837	11 (2) In the case of errors attributable to the Illinois
838	838	12 Department or any of its claims processing intermediaries
839	839	13 which result in an inability to receive, process, or
840	840	14 adjudicate a claim, the 180-day period shall not begin
841	841	15 until the provider has been notified of the error.
842	842	16 (3) In the case of a provider for whom the Illinois
843	843	17 Department initiates the monthly billing process.
844	844	18 (4) In the case of a provider operated by a unit of
845	845	19 local government with a population exceeding 3,000,000
846	846	20 when local government funds finance federal participation
847	847	21 for claims payments.
848	848	22 For claims for services rendered during a period for which
849	849	23 a recipient received retroactive eligibility, claims must be
850	850	24 filed within 180 days after the Department determines the
851	851	25 applicant is eligible. For claims for which the Illinois
852	852	26 Department is not the primary payer, claims must be submitted
853	853
854	854
855	855
856	856
857	857
858	858	SB0200 - 23 - LRB103 03520 KTG 48526 b
859	859
860	860
861	861	SB0200- 24 -LRB103 03520 KTG 48526 b SB0200 - 24 - LRB103 03520 KTG 48526 b
862	862	SB0200 - 24 - LRB103 03520 KTG 48526 b
863	863	1 to the Illinois Department within 180 days after the final
864	864	2 adjudication by the primary payer.
865	865	3 In the case of long term care facilities, within 120
866	866	4 calendar days of receipt by the facility of required
867	867	5 prescreening information, new admissions with associated
868	868	6 admission documents shall be submitted through the Medical
869	869	7 Electronic Data Interchange (MEDI) or the Recipient
870	870	8 Eligibility Verification (REV) System or shall be submitted
871	871	9 directly to the Department of Human Services using required
872	872	10 admission forms. Effective September 1, 2014, admission
873	873	11 documents, including all prescreening information, must be
874	874	12 submitted through MEDI or REV. Confirmation numbers assigned
875	875	13 to an accepted transaction shall be retained by a facility to
876	876	14 verify timely submittal. Once an admission transaction has
877	877	15 been completed, all resubmitted claims following prior
878	878	16 rejection are subject to receipt no later than 180 days after
879	879	17 the admission transaction has been completed.
880	880	18 Claims that are not submitted and received in compliance
881	881	19 with the foregoing requirements shall not be eligible for
882	882	20 payment under the medical assistance program, and the State
883	883	21 shall have no liability for payment of those claims.
884	884	22 To the extent consistent with applicable information and
885	885	23 privacy, security, and disclosure laws, State and federal
886	886	24 agencies and departments shall provide the Illinois Department
887	887	25 access to confidential and other information and data
888	888	26 necessary to perform eligibility and payment verifications and
889	889
890	890
891	891
892	892
893	893
894	894	SB0200 - 24 - LRB103 03520 KTG 48526 b
895	895
896	896
897	897	SB0200- 25 -LRB103 03520 KTG 48526 b SB0200 - 25 - LRB103 03520 KTG 48526 b
898	898	SB0200 - 25 - LRB103 03520 KTG 48526 b
899	899	1 other Illinois Department functions. This includes, but is not
900	900	2 limited to: information pertaining to licensure;
901	901	3 certification; earnings; immigration status; citizenship; wage
902	902	4 reporting; unearned and earned income; pension income;
903	903	5 employment; supplemental security income; social security
904	904	6 numbers; National Provider Identifier (NPI) numbers; the
905	905	7 National Practitioner Data Bank (NPDB); program and agency
906	906	8 exclusions; taxpayer identification numbers; tax delinquency;
907	907	9 corporate information; and death records.
908	908	10 The Illinois Department shall enter into agreements with
909	909	11 State agencies and departments, and is authorized to enter
910	910	12 into agreements with federal agencies and departments, under
911	911	13 which such agencies and departments shall share data necessary
912	912	14 for medical assistance program integrity functions and
913	913	15 oversight. The Illinois Department shall develop, in
914	914	16 cooperation with other State departments and agencies, and in
915	915	17 compliance with applicable federal laws and regulations,
916	916	18 appropriate and effective methods to share such data. At a
917	917	19 minimum, and to the extent necessary to provide data sharing,
918	918	20 the Illinois Department shall enter into agreements with State
919	919	21 agencies and departments, and is authorized to enter into
920	920	22 agreements with federal agencies and departments, including,
921	921	23 but not limited to: the Secretary of State; the Department of
922	922	24 Revenue; the Department of Public Health; the Department of
923	923	25 Human Services; and the Department of Financial and
924	924	26 Professional Regulation.
925	925
926	926
927	927
928	928
929	929
930	930	SB0200 - 25 - LRB103 03520 KTG 48526 b
931	931
932	932
933	933	SB0200- 26 -LRB103 03520 KTG 48526 b SB0200 - 26 - LRB103 03520 KTG 48526 b
934	934	SB0200 - 26 - LRB103 03520 KTG 48526 b
935	935	1 Beginning in fiscal year 2013, the Illinois Department
936	936	2 shall set forth a request for information to identify the
937	937	3 benefits of a pre-payment, post-adjudication, and post-edit
938	938	4 claims system with the goals of streamlining claims processing
939	939	5 and provider reimbursement, reducing the number of pending or
940	940	6 rejected claims, and helping to ensure a more transparent
941	941	7 adjudication process through the utilization of: (i) provider
942	942	8 data verification and provider screening technology; and (ii)
943	943	9 clinical code editing; and (iii) pre-pay, pre- or
944	944	10 post-adjudicated predictive modeling with an integrated case
945	945	11 management system with link analysis. Such a request for
946	946	12 information shall not be considered as a request for proposal
947	947	13 or as an obligation on the part of the Illinois Department to
948	948	14 take any action or acquire any products or services.
949	949	15 The Illinois Department shall establish policies,
950	950	16 procedures, standards and criteria by rule for the
951	951	17 acquisition, repair and replacement of orthotic and prosthetic
952	952	18 devices and durable medical equipment. Such rules shall
953	953	19 provide, but not be limited to, the following services: (1)
954	954	20 immediate repair or replacement of such devices by recipients;
955	955	21 and (2) rental, lease, purchase or lease-purchase of durable
956	956	22 medical equipment in a cost-effective manner, taking into
957	957	23 consideration the recipient's medical prognosis, the extent of
958	958	24 the recipient's needs, and the requirements and costs for
959	959	25 maintaining such equipment. Subject to prior approval, such
960	960	26 rules shall enable a recipient to temporarily acquire and use
961	961
962	962
963	963
964	964
965	965
966	966	SB0200 - 26 - LRB103 03520 KTG 48526 b
967	967
968	968
969	969	SB0200- 27 -LRB103 03520 KTG 48526 b SB0200 - 27 - LRB103 03520 KTG 48526 b
970	970	SB0200 - 27 - LRB103 03520 KTG 48526 b
971	971	1 alternative or substitute devices or equipment pending repairs
972	972	2 or replacements of any device or equipment previously
973	973	3 authorized for such recipient by the Department.
974	974	4 Notwithstanding any provision of Section 5-5f to the contrary,
975	975	5 the Department may, by rule, exempt certain replacement
976	976	6 wheelchair parts from prior approval and, for wheelchairs,
977	977	7 wheelchair parts, wheelchair accessories, and related seating
978	978	8 and positioning items, determine the wholesale price by
979	979	9 methods other than actual acquisition costs.
980	980	10 The Department shall require, by rule, all providers of
981	981	11 durable medical equipment to be accredited by an accreditation
982	982	12 organization approved by the federal Centers for Medicare and
983	983	13 Medicaid Services and recognized by the Department in order to
984	984	14 bill the Department for providing durable medical equipment to
985	985	15 recipients. No later than 15 months after the effective date
986	986	16 of the rule adopted pursuant to this paragraph, all providers
987	987	17 must meet the accreditation requirement.
988	988	18 In order to promote environmental responsibility, meet the
989	989	19 needs of recipients and enrollees, and achieve significant
990	990	20 cost savings, the Department, or a managed care organization
991	991	21 under contract with the Department, may provide recipients or
992	992	22 managed care enrollees who have a prescription or Certificate
993	993	23 of Medical Necessity access to refurbished durable medical
994	994	24 equipment under this Section (excluding prosthetic and
995	995	25 orthotic devices as defined in the Orthotics, Prosthetics, and
996	996	26 Pedorthics Practice Act and complex rehabilitation technology
997	997
998	998
999	999
1000	1000
1001	1001
1002	1002	SB0200 - 27 - LRB103 03520 KTG 48526 b
1003	1003
1004	1004
1005	1005	SB0200- 28 -LRB103 03520 KTG 48526 b SB0200 - 28 - LRB103 03520 KTG 48526 b
1006	1006	SB0200 - 28 - LRB103 03520 KTG 48526 b
1007	1007	1 products and associated services) through the State's
1008	1008	2 assistive technology program's reutilization program, using
1009	1009	3 staff with the Assistive Technology Professional (ATP)
1010	1010	4 Certification if the refurbished durable medical equipment:
1011	1011	5 (i) is available; (ii) is less expensive, including shipping
1012	1012	6 costs, than new durable medical equipment of the same type;
1013	1013	7 (iii) is able to withstand at least 3 years of use; (iv) is
1014	1014	8 cleaned, disinfected, sterilized, and safe in accordance with
1015	1015	9 federal Food and Drug Administration regulations and guidance
1016	1016	10 governing the reprocessing of medical devices in health care
1017	1017	11 settings; and (v) equally meets the needs of the recipient or
1018	1018	12 enrollee. The reutilization program shall confirm that the
1019	1019	13 recipient or enrollee is not already in receipt of the same or
1020	1020	14 similar equipment from another service provider, and that the
1021	1021	15 refurbished durable medical equipment equally meets the needs
1022	1022	16 of the recipient or enrollee. Nothing in this paragraph shall
1023	1023	17 be construed to limit recipient or enrollee choice to obtain
1024	1024	18 new durable medical equipment or place any additional prior
1025	1025	19 authorization conditions on enrollees of managed care
1026	1026	20 organizations.
1027	1027	21 The Department shall execute, relative to the nursing home
1028	1028	22 prescreening project, written inter-agency agreements with the
1029	1029	23 Department of Human Services and the Department on Aging, to
1030	1030	24 effect the following: (i) intake procedures and common
1031	1031	25 eligibility criteria for those persons who are receiving
1032	1032	26 non-institutional services; and (ii) the establishment and
1033	1033
1034	1034
1035	1035
1036	1036
1037	1037
1038	1038	SB0200 - 28 - LRB103 03520 KTG 48526 b
1039	1039
1040	1040
1041	1041	SB0200- 29 -LRB103 03520 KTG 48526 b SB0200 - 29 - LRB103 03520 KTG 48526 b
1042	1042	SB0200 - 29 - LRB103 03520 KTG 48526 b
1043	1043	1 development of non-institutional services in areas of the
1044	1044	2 State where they are not currently available or are
1045	1045	3 undeveloped; and (iii) notwithstanding any other provision of
1046	1046	4 law, subject to federal approval, on and after July 1, 2012, an
1047	1047	5 increase in the determination of need (DON) scores from 29 to
1048	1048	6 37 for applicants for institutional and home and
1049	1049	7 community-based long term care; if and only if federal
1050	1050	8 approval is not granted, the Department may, in conjunction
1051	1051	9 with other affected agencies, implement utilization controls
1052	1052	10 or changes in benefit packages to effectuate a similar savings
1053	1053	11 amount for this population; and (iv) no later than July 1,
1054	1054	12 2013, minimum level of care eligibility criteria for
1055	1055	13 institutional and home and community-based long term care; and
1056	1056	14 (v) no later than October 1, 2013, establish procedures to
1057	1057	15 permit long term care providers access to eligibility scores
1058	1058	16 for individuals with an admission date who are seeking or
1059	1059	17 receiving services from the long term care provider. In order
1060	1060	18 to select the minimum level of care eligibility criteria, the
1061	1061	19 Governor shall establish a workgroup that includes affected
1062	1062	20 agency representatives and stakeholders representing the
1063	1063	21 institutional and home and community-based long term care
1064	1064	22 interests. This Section shall not restrict the Department from
1065	1065	23 implementing lower level of care eligibility criteria for
1066	1066	24 community-based services in circumstances where federal
1067	1067	25 approval has been granted.
1068	1068	26 The Illinois Department shall develop and operate, in
1069	1069
1070	1070
1071	1071
1072	1072
1073	1073
1074	1074	SB0200 - 29 - LRB103 03520 KTG 48526 b
1075	1075
1076	1076
1077	1077	SB0200- 30 -LRB103 03520 KTG 48526 b SB0200 - 30 - LRB103 03520 KTG 48526 b
1078	1078	SB0200 - 30 - LRB103 03520 KTG 48526 b
1079	1079	1 cooperation with other State Departments and agencies and in
1080	1080	2 compliance with applicable federal laws and regulations,
1081	1081	3 appropriate and effective systems of health care evaluation
1082	1082	4 and programs for monitoring of utilization of health care
1083	1083	5 services and facilities, as it affects persons eligible for
1084	1084	6 medical assistance under this Code.
1085	1085	7 The Illinois Department shall report annually to the
1086	1086	8 General Assembly, no later than the second Friday in April of
1087	1087	9 1979 and each year thereafter, in regard to:
1088	1088	10 (a) actual statistics and trends in utilization of
1089	1089	11 medical services by public aid recipients;
1090	1090	12 (b) actual statistics and trends in the provision of
1091	1091	13 the various medical services by medical vendors;
1092	1092	14 (c) current rate structures and proposed changes in
1093	1093	15 those rate structures for the various medical vendors; and
1094	1094	16 (d) efforts at utilization review and control by the
1095	1095	17 Illinois Department.
1096	1096	18 The period covered by each report shall be the 3 years
1097	1097	19 ending on the June 30 prior to the report. The report shall
1098	1098	20 include suggested legislation for consideration by the General
1099	1099	21 Assembly. The requirement for reporting to the General
1100	1100	22 Assembly shall be satisfied by filing copies of the report as
1101	1101	23 required by Section 3.1 of the General Assembly Organization
1102	1102	24 Act, and filing such additional copies with the State
1103	1103	25 Government Report Distribution Center for the General Assembly
1104	1104	26 as is required under paragraph (t) of Section 7 of the State
1105	1105
1106	1106
1107	1107
1108	1108
1109	1109
1110	1110	SB0200 - 30 - LRB103 03520 KTG 48526 b
1111	1111
1112	1112
1113	1113	SB0200- 31 -LRB103 03520 KTG 48526 b SB0200 - 31 - LRB103 03520 KTG 48526 b
1114	1114	SB0200 - 31 - LRB103 03520 KTG 48526 b
1115	1115	1 Library Act.
1116	1116	2 Rulemaking authority to implement Public Act 95-1045, if
1117	1117	3 any, is conditioned on the rules being adopted in accordance
1118	1118	4 with all provisions of the Illinois Administrative Procedure
1119	1119	5 Act and all rules and procedures of the Joint Committee on
1120	1120	6 Administrative Rules; any purported rule not so adopted, for
1121	1121	7 whatever reason, is unauthorized.
1122	1122	8 On and after July 1, 2012, the Department shall reduce any
1123	1123	9 rate of reimbursement for services or other payments or alter
1124	1124	10 any methodologies authorized by this Code to reduce any rate
1125	1125	11 of reimbursement for services or other payments in accordance
1126	1126	12 with Section 5-5e.
1127	1127	13 Because kidney transplantation can be an appropriate,
1128	1128	14 cost-effective alternative to renal dialysis when medically
1129	1129	15 necessary and notwithstanding the provisions of Section 1-11
1130	1130	16 of this Code, beginning October 1, 2014, the Department shall
1131	1131	17 cover kidney transplantation for noncitizens with end-stage
1132	1132	18 renal disease who are not eligible for comprehensive medical
1133	1133	19 benefits, who meet the residency requirements of Section 5-3
1134	1134	20 of this Code, and who would otherwise meet the financial
1135	1135	21 requirements of the appropriate class of eligible persons
1136	1136	22 under Section 5-2 of this Code. To qualify for coverage of
1137	1137	23 kidney transplantation, such person must be receiving
1138	1138	24 emergency renal dialysis services covered by the Department.
1139	1139	25 Providers under this Section shall be prior approved and
1140	1140	26 certified by the Department to perform kidney transplantation
1141	1141
1142	1142
1143	1143
1144	1144
1145	1145
1146	1146	SB0200 - 31 - LRB103 03520 KTG 48526 b
1147	1147
1148	1148
1149	1149	SB0200- 32 -LRB103 03520 KTG 48526 b SB0200 - 32 - LRB103 03520 KTG 48526 b
1150	1150	SB0200 - 32 - LRB103 03520 KTG 48526 b
1151	1151	1 and the services under this Section shall be limited to
1152	1152	2 services associated with kidney transplantation.
1153	1153	3 Notwithstanding any other provision of this Code to the
1154	1154	4 contrary, on or after July 1, 2015, all FDA approved forms of
1155	1155	5 medication assisted treatment prescribed for the treatment of
1156	1156	6 alcohol dependence or treatment of opioid dependence shall be
1157	1157	7 covered under both fee for service and managed care medical
1158	1158	8 assistance programs for persons who are otherwise eligible for
1159	1159	9 medical assistance under this Article and shall not be subject
1160	1160	10 to any (1) utilization control, other than those established
1161	1161	11 under the American Society of Addiction Medicine patient
1162	1162	12 placement criteria, (2) prior authorization mandate, or (3)
1163	1163	13 lifetime restriction limit mandate.
1164	1164	14 On or after July 1, 2015, opioid antagonists prescribed
1165	1165	15 for the treatment of an opioid overdose, including the
1166	1166	16 medication product, administration devices, and any pharmacy
1167	1167	17 fees or hospital fees related to the dispensing, distribution,
1168	1168	18 and administration of the opioid antagonist, shall be covered
1169	1169	19 under the medical assistance program for persons who are
1170	1170	20 otherwise eligible for medical assistance under this Article.
1171	1171	21 As used in this Section, "opioid antagonist" means a drug that
1172	1172	22 binds to opioid receptors and blocks or inhibits the effect of
1173	1173	23 opioids acting on those receptors, including, but not limited
1174	1174	24 to, naloxone hydrochloride or any other similarly acting drug
1175	1175	25 approved by the U.S. Food and Drug Administration. The
1176	1176	26 Department shall not impose a copayment on the coverage
1177	1177
1178	1178
1179	1179
1180	1180
1181	1181
1182	1182	SB0200 - 32 - LRB103 03520 KTG 48526 b
1183	1183
1184	1184
1185	1185	SB0200- 33 -LRB103 03520 KTG 48526 b SB0200 - 33 - LRB103 03520 KTG 48526 b
1186	1186	SB0200 - 33 - LRB103 03520 KTG 48526 b
1187	1187	1 provided for naloxone hydrochloride under the medical
1188	1188	2 assistance program.
1189	1189	3 Upon federal approval, the Department shall provide
1190	1190	4 coverage and reimbursement for all drugs that are approved for
1191	1191	5 marketing by the federal Food and Drug Administration and that
1192	1192	6 are recommended by the federal Public Health Service or the
1193	1193	7 United States Centers for Disease Control and Prevention for
1194	1194	8 pre-exposure prophylaxis and related pre-exposure prophylaxis
1195	1195	9 services, including, but not limited to, HIV and sexually
1196	1196	10 transmitted infection screening, treatment for sexually
1197	1197	11 transmitted infections, medical monitoring, assorted labs, and
1198	1198	12 counseling to reduce the likelihood of HIV infection among
1199	1199	13 individuals who are not infected with HIV but who are at high
1200	1200	14 risk of HIV infection.
1201	1201	15 A federally qualified health center, as defined in Section
1202	1202	16 1905(l)(2)(B) of the federal Social Security Act, shall be
1203	1203	17 reimbursed by the Department in accordance with the federally
1204	1204	18 qualified health center's encounter rate for services provided
1205	1205	19 to medical assistance recipients that are performed by a
1206	1206	20 dental hygienist, as defined under the Illinois Dental
1207	1207	21 Practice Act, working under the general supervision of a
1208	1208	22 dentist and employed by a federally qualified health center.
1209	1209	23 Within 90 days after October 8, 2021 (the effective date
1210	1210	24 of Public Act 102-665), the Department shall seek federal
1211	1211	25 approval of a State Plan amendment to expand coverage for
1212	1212	26 family planning services that includes presumptive eligibility
1213	1213
1214	1214
1215	1215
1216	1216
1217	1217
1218	1218	SB0200 - 33 - LRB103 03520 KTG 48526 b
1219	1219
1220	1220
1221	1221	SB0200- 34 -LRB103 03520 KTG 48526 b SB0200 - 34 - LRB103 03520 KTG 48526 b
1222	1222	SB0200 - 34 - LRB103 03520 KTG 48526 b
1223	1223	1 to individuals whose income is at or below 208% of the federal
1224	1224	2 poverty level. Coverage under this Section shall be effective
1225	1225	3 beginning no later than December 1, 2022.
1226	1226	4 Subject to approval by the federal Centers for Medicare
1227	1227	5 and Medicaid Services of a Title XIX State Plan amendment
1228	1228	6 electing the Program of All-Inclusive Care for the Elderly
1229	1229	7 (PACE) as a State Medicaid option, as provided for by Subtitle
1230	1230	8 I (commencing with Section 4801) of Title IV of the Balanced
1231	1231	9 Budget Act of 1997 (Public Law 105-33) and Part 460
1232	1232	10 (commencing with Section 460.2) of Subchapter E of Title 42 of
1233	1233	11 the Code of Federal Regulations, PACE program services shall
1234	1234	12 become a covered benefit of the medical assistance program,
1235	1235	13 subject to criteria established in accordance with all
1236	1236	14 applicable laws.
1237	1237	15 Notwithstanding any other provision of this Code,
1238	1238	16 community-based pediatric palliative care from a trained
1239	1239	17 interdisciplinary team shall be covered under the medical
1240	1240	18 assistance program as provided in Section 15 of the Pediatric
1241	1241	19 Palliative Care Act.
1242	1242	20 Notwithstanding any other provision of this Code, within
1243	1243	21 12 months after June 2, 2022 (the effective date of Public Act
1244	1244	22 102-1037) this amendatory Act of the 102nd General Assembly
1245	1245	23 and subject to federal approval, acupuncture services
1246	1246	24 performed by an acupuncturist licensed under the Acupuncture
1247	1247	25 Practice Act who is acting within the scope of his or her
1248	1248	26 license shall be covered under the medical assistance program.
1249	1249
1250	1250
1251	1251
1252	1252
1253	1253
1254	1254	SB0200 - 34 - LRB103 03520 KTG 48526 b
1255	1255
1256	1256
1257	1257	SB0200- 35 -LRB103 03520 KTG 48526 b SB0200 - 35 - LRB103 03520 KTG 48526 b
1258	1258	SB0200 - 35 - LRB103 03520 KTG 48526 b
1259	1259	1 The Department shall apply for any federal waiver or State
1260	1260	2 Plan amendment, if required, to implement this paragraph. The
1261	1261	3 Department may adopt any rules, including standards and
1262	1262	4 criteria, necessary to implement this paragraph.
1263	1263	5 (Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
1264	1264	6 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1265	1265	7 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1266	1266	8 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
1267	1267	9 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1268	1268	10 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
1269	1269	11 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1270	1270	12 1-1-23; revised 8-9-22.)
1271	1271	13 (305 ILCS 5/5-5.06f new)
1272	1272	14 Sec. 5-5.06f. Medically necessary orthodontic services;
1273	1273	15 criteria for coverage.
1274	1274	16 (a) As used in this Section, "medically necessary
1275	1275	17 orthodontic services" means orthodontic services to prevent,
1276	1276	18 diagnose, minimize, alleviate, correct, or resolve a
1277	1277	19 malocclusion (including craniofacial abnormalities and
1278	1278	20 traumatic or pathologic anatomical deviations) that causes
1279	1279	21 pain or suffering, physical deformity, or significant
1280	1280	22 malfunction, that aggravates another condition, or that
1281	1281	23 results in further injury or infirmity.
1282	1282	24 (b) On and after July 1, 2023, the Department shall use the
1283	1283	25 following auto-qualifiers when determining whether an
1284	1284
1285	1285
1286	1286
1287	1287
1288	1288
1289	1289	SB0200 - 35 - LRB103 03520 KTG 48526 b
1290	1290
1291	1291
1292	1292	SB0200- 36 -LRB103 03520 KTG 48526 b SB0200 - 36 - LRB103 03520 KTG 48526 b
1293	1293	SB0200 - 36 - LRB103 03520 KTG 48526 b
1294	1294	1 individual, who is otherwise eligible for medical assistance,
1295	1295	2 is also eligible for coverage for a medically necessary
1296	1296	3 orthodontic service:
1297	1297	4 (1) Overjet: 9 mm or more.
1298	1298	5 (2) Reverse overjet: 3.5 mm or more.
1299	1299	6 (3) Anterior or posterior crossbite of 3 or more teeth
1300	1300	7 per arch.
1301	1301	8 (4) Lateral or anterior open bite: 2 mm or more, of 4
1302	1302	9 or more teeth per arch.
1303	1303	10 (5) Impinging overbite with evidence of occlusal
1304	1304	11 contact into the opposing soft tissue.
1305	1305	12 (6) Impactions where eruption is impeded, but
1306	1306	13 extraction is not indicated (excluding third molars).
1307	1307	14 (7) Jaws or dentition which are profoundly affected by
1308	1308	15 a congenital or developmental disorder (craniofacial
1309	1309	16 anomalies), trauma, or pathology.
1310	1310	17 (8) Congenitally missing teeth (excluding third
1311	1311	18 molars) of at least one tooth per quadrant.
1312	1312	19 (9) Crowding or spacing of 10 mm or more, in either the
1313	1313	20 maxillary or mandibular arch (excluding third molars).
1314	1314	21 (c) If the Department denies a claim for a medically
1315	1315	22 necessary orthodontic service, the Department must, at a
1316	1316	23 minimum, provide the following information to the provider of
1317	1317	24 the orthodontic service:
1318	1318	25 (1) The actual score of the orthodontic case.
1319	1319	26 (2) The name of the dentist or orthodontist who scored
1320	1320
1321	1321
1322	1322
1323	1323
1324	1324
1325	1325	SB0200 - 36 - LRB103 03520 KTG 48526 b
1326	1326
1327	1327
1328	1328	SB0200- 37 -LRB103 03520 KTG 48526 b SB0200 - 37 - LRB103 03520 KTG 48526 b
1329	1329	SB0200 - 37 - LRB103 03520 KTG 48526 b
1330	1330	1 the orthodontic case.
1331	1331	2 (3) A detailed scoring sheet outlining the reasons for
1332	1332	3 the score of the orthodontic case.
1333	1333	4 (4) Instructions on how to appeal the denied claim.
1334	1334
1335	1335
1336	1336
1337	1337
1338	1338
1339	1339	SB0200 - 37 - LRB103 03520 KTG 48526 b