Bill Amendment: IL HB2511 | 2017-2018 | 100th General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: MEDICAID-EXCEPTION TO RX LIMIT
Status: 2019-01-08 - Session Sine Die [HB2511 Detail]
Download: Illinois-2017-HB2511-House_Amendment_002.html
Bill Title: MEDICAID-EXCEPTION TO RX LIMIT
Status: 2019-01-08 - Session Sine Die [HB2511 Detail]
Download: Illinois-2017-HB2511-House_Amendment_002.html
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1 | AMENDMENT TO HOUSE BILL 2511
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2 | AMENDMENT NO. ______. Amend House Bill 2511, AS AMENDED, | ||||||
3 | with reference to page and line numbers of House Amendment No. | ||||||
4 | 1 as follows:
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5 | on page 1, line 5, by replacing "Section" with "Sections 5-5 | ||||||
6 | and"; and
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7 | on page 1, immediately below line 5, by inserting the | ||||||
8 | following:
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9 | "(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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10 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
11 | rule, shall
determine the quantity and quality of and the rate | ||||||
12 | of reimbursement for the
medical assistance for which
payment | ||||||
13 | will be authorized, and the medical services to be provided,
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14 | which may include all or part of the following: (1) inpatient | ||||||
15 | hospital
services; (2) outpatient hospital services; (3) other |
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1 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
2 | services; (5) physicians'
services whether furnished in the | ||||||
3 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
4 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
5 | care furnished by licensed practitioners; (7)
home health care | ||||||
6 | services; (8) private duty nursing service; (9) clinic
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7 | services; (10) dental services, including prevention and | ||||||
8 | treatment of periodontal disease and dental caries disease for | ||||||
9 | pregnant women, provided by an individual licensed to practice | ||||||
10 | dentistry or dental surgery; for purposes of this item (10), | ||||||
11 | "dental services" means diagnostic, preventive, or corrective | ||||||
12 | procedures provided by or under the supervision of a dentist in | ||||||
13 | the practice of his or her profession; (11) physical therapy | ||||||
14 | and related
services; (12) prescribed drugs, dentures, and | ||||||
15 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
16 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
17 | whichever the person may select; (13) other
diagnostic, | ||||||
18 | screening, preventive, and rehabilitative services, including | ||||||
19 | to ensure that the individual's need for intervention or | ||||||
20 | treatment of mental disorders or substance use disorders or | ||||||
21 | co-occurring mental health and substance use disorders is | ||||||
22 | determined using a uniform screening, assessment, and | ||||||
23 | evaluation process inclusive of criteria, for children and | ||||||
24 | adults; for purposes of this item (13), a uniform screening, | ||||||
25 | assessment, and evaluation process refers to a process that | ||||||
26 | includes an appropriate evaluation and, as warranted, a |
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1 | referral; "uniform" does not mean the use of a singular | ||||||
2 | instrument, tool, or process that all must utilize; (14)
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3 | transportation and such other expenses as may be necessary; | ||||||
4 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
5 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
6 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
7 | assault, including
examinations and laboratory tests to | ||||||
8 | discover evidence which may be used in
criminal proceedings | ||||||
9 | arising from the sexual assault; (16) the
diagnosis and | ||||||
10 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
11 | care, and any other type of remedial care recognized
under the | ||||||
12 | laws of this State. The term "any other type of remedial care" | ||||||
13 | shall
include nursing care and nursing home service for persons | ||||||
14 | who rely on
treatment by spiritual means alone through prayer | ||||||
15 | for healing.
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16 | Notwithstanding any other provision of this Section, a | ||||||
17 | comprehensive
tobacco use cessation program that includes | ||||||
18 | purchasing prescription drugs or
prescription medical devices | ||||||
19 | approved by the Food and Drug Administration shall
be covered | ||||||
20 | under the medical assistance
program under this Article for | ||||||
21 | persons who are otherwise eligible for
assistance under this | ||||||
22 | Article.
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23 | Notwithstanding any other provision of this Code, | ||||||
24 | reproductive health care that is otherwise legal in Illinois | ||||||
25 | shall be covered under the medical assistance program for | ||||||
26 | persons who are otherwise eligible for medical assistance under |
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1 | this Article. | ||||||
2 | Notwithstanding any other provision of this Code, the | ||||||
3 | Illinois
Department may not require, as a condition of payment | ||||||
4 | for any laboratory
test authorized under this Article, that a | ||||||
5 | physician's handwritten signature
appear on the laboratory | ||||||
6 | test order form. The Illinois Department may,
however, impose | ||||||
7 | other appropriate requirements regarding laboratory test
order | ||||||
8 | documentation.
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9 | Upon receipt of federal approval of an amendment to the | ||||||
10 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
11 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
12 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
13 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
14 | that its vendor or vendors are enrolled as providers in the | ||||||
15 | medical assistance program and in any capitated Medicaid | ||||||
16 | managed care entity (MCE) serving individuals enrolled in a | ||||||
17 | school within the CPS system. Under any contract procured under | ||||||
18 | this provision, the vendor or vendors must serve only | ||||||
19 | individuals enrolled in a school within the CPS system. Claims | ||||||
20 | for services provided by CPS's vendor or vendors to recipients | ||||||
21 | of benefits in the medical assistance program under this Code, | ||||||
22 | the Children's Health Insurance Program, or the Covering ALL | ||||||
23 | KIDS Health Insurance Program shall be submitted to the | ||||||
24 | Department or the MCE in which the individual is enrolled for | ||||||
25 | payment and shall be reimbursed at the Department's or the | ||||||
26 | MCE's established rates or rate methodologies for eyeglasses. |
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1 | On and after July 1, 2012, the Department of Healthcare and | ||||||
2 | Family Services may provide the following services to
persons
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3 | eligible for assistance under this Article who are | ||||||
4 | participating in
education, training or employment programs | ||||||
5 | operated by the Department of Human
Services as successor to | ||||||
6 | the Department of Public Aid:
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7 | (1) dental services provided by or under the | ||||||
8 | supervision of a dentist; and
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9 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
10 | diseases of the
eye, or by an optometrist, whichever the | ||||||
11 | person may select.
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12 | Notwithstanding any other provision of this Code and | ||||||
13 | subject to federal approval, the Department may adopt rules to | ||||||
14 | allow a dentist who is volunteering his or her service at no | ||||||
15 | cost to render dental services through an enrolled | ||||||
16 | not-for-profit health clinic without the dentist personally | ||||||
17 | enrolling as a participating provider in the medical assistance | ||||||
18 | program. A not-for-profit health clinic shall include a public | ||||||
19 | health clinic or Federally Qualified Health Center or other | ||||||
20 | enrolled provider, as determined by the Department, through | ||||||
21 | which dental services covered under this Section are performed. | ||||||
22 | The Department shall establish a process for payment of claims | ||||||
23 | for reimbursement for covered dental services rendered under | ||||||
24 | this provision. | ||||||
25 | The Illinois Department, by rule, may distinguish and | ||||||
26 | classify the
medical services to be provided only in accordance |
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1 | with the classes of
persons designated in Section 5-2.
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2 | The Department of Healthcare and Family Services must | ||||||
3 | provide coverage and reimbursement for amino acid-based | ||||||
4 | elemental formulas, regardless of delivery method, for the | ||||||
5 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
6 | short bowel syndrome when the prescribing physician has issued | ||||||
7 | a written order stating that the amino acid-based elemental | ||||||
8 | formula is medically necessary.
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9 | The Illinois Department shall authorize the provision of, | ||||||
10 | and shall
authorize payment for, screening by low-dose | ||||||
11 | mammography for the presence of
occult breast cancer for women | ||||||
12 | 35 years of age or older who are eligible
for medical | ||||||
13 | assistance under this Article, as follows: | ||||||
14 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
15 | age.
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16 | (B) An annual mammogram for women 40 years of age or | ||||||
17 | older. | ||||||
18 | (C) A mammogram at the age and intervals considered | ||||||
19 | medically necessary by the woman's health care provider for | ||||||
20 | women under 40 years of age and having a family history of | ||||||
21 | breast cancer, prior personal history of breast cancer, | ||||||
22 | positive genetic testing, or other risk factors. | ||||||
23 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
24 | entire breast or breasts if a mammogram demonstrates | ||||||
25 | heterogeneous or dense breast tissue, when medically | ||||||
26 | necessary as determined by a physician licensed to practice |
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1 | medicine in all of its branches. | ||||||
2 | (E) A screening MRI when medically necessary, as | ||||||
3 | determined by a physician licensed to practice medicine in | ||||||
4 | all of its branches. | ||||||
5 | All screenings
shall
include a physical breast exam, | ||||||
6 | instruction on self-examination and
information regarding the | ||||||
7 | frequency of self-examination and its value as a
preventative | ||||||
8 | tool. For purposes of this Section, "low-dose mammography" | ||||||
9 | means
the x-ray examination of the breast using equipment | ||||||
10 | dedicated specifically
for mammography, including the x-ray | ||||||
11 | tube, filter, compression device,
and image receptor, with an | ||||||
12 | average radiation exposure delivery
of less than one rad per | ||||||
13 | breast for 2 views of an average size breast.
The term also | ||||||
14 | includes digital mammography and includes breast | ||||||
15 | tomosynthesis. As used in this Section, the term "breast | ||||||
16 | tomosynthesis" means a radiologic procedure that involves the | ||||||
17 | acquisition of projection images over the stationary breast to | ||||||
18 | produce cross-sectional digital three-dimensional images of | ||||||
19 | the breast. If, at any time, the Secretary of the United States | ||||||
20 | Department of Health and Human Services, or its successor | ||||||
21 | agency, promulgates rules or regulations to be published in the | ||||||
22 | Federal Register or publishes a comment in the Federal Register | ||||||
23 | or issues an opinion, guidance, or other action that would | ||||||
24 | require the State, pursuant to any provision of the Patient | ||||||
25 | Protection and Affordable Care Act (Public Law 111-148), | ||||||
26 | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any |
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1 | successor provision, to defray the cost of any coverage for | ||||||
2 | breast tomosynthesis outlined in this paragraph, then the | ||||||
3 | requirement that an insurer cover breast tomosynthesis is | ||||||
4 | inoperative other than any such coverage authorized under | ||||||
5 | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | ||||||
6 | the State shall not assume any obligation for the cost of | ||||||
7 | coverage for breast tomosynthesis set forth in this paragraph.
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8 | On and after January 1, 2016, the Department shall ensure | ||||||
9 | that all networks of care for adult clients of the Department | ||||||
10 | include access to at least one breast imaging Center of Imaging | ||||||
11 | Excellence as certified by the American College of Radiology. | ||||||
12 | On and after January 1, 2012, providers participating in a | ||||||
13 | quality improvement program approved by the Department shall be | ||||||
14 | reimbursed for screening and diagnostic mammography at the same | ||||||
15 | rate as the Medicare program's rates, including the increased | ||||||
16 | reimbursement for digital mammography. | ||||||
17 | The Department shall convene an expert panel including | ||||||
18 | representatives of hospitals, free-standing mammography | ||||||
19 | facilities, and doctors, including radiologists, to establish | ||||||
20 | quality standards for mammography. | ||||||
21 | On and after January 1, 2017, providers participating in a | ||||||
22 | breast cancer treatment quality improvement program approved | ||||||
23 | by the Department shall be reimbursed for breast cancer | ||||||
24 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
25 | program's rates for the data elements included in the breast | ||||||
26 | cancer treatment quality program. |
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1 | The Department shall convene an expert panel, including | ||||||
2 | representatives of hospitals, free standing breast cancer | ||||||
3 | treatment centers, breast cancer quality organizations, and | ||||||
4 | doctors, including breast surgeons, reconstructive breast | ||||||
5 | surgeons, oncologists, and primary care providers to establish | ||||||
6 | quality standards for breast cancer treatment. | ||||||
7 | Subject to federal approval, the Department shall | ||||||
8 | establish a rate methodology for mammography at federally | ||||||
9 | qualified health centers and other encounter-rate clinics. | ||||||
10 | These clinics or centers may also collaborate with other | ||||||
11 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
12 | Department shall report to the General Assembly on the status | ||||||
13 | of the provision set forth in this paragraph. | ||||||
14 | The Department shall establish a methodology to remind | ||||||
15 | women who are age-appropriate for screening mammography, but | ||||||
16 | who have not received a mammogram within the previous 18 | ||||||
17 | months, of the importance and benefit of screening mammography. | ||||||
18 | The Department shall work with experts in breast cancer | ||||||
19 | outreach and patient navigation to optimize these reminders and | ||||||
20 | shall establish a methodology for evaluating their | ||||||
21 | effectiveness and modifying the methodology based on the | ||||||
22 | evaluation. | ||||||
23 | The Department shall establish a performance goal for | ||||||
24 | primary care providers with respect to their female patients | ||||||
25 | over age 40 receiving an annual mammogram. This performance | ||||||
26 | goal shall be used to provide additional reimbursement in the |
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1 | form of a quality performance bonus to primary care providers | ||||||
2 | who meet that goal. | ||||||
3 | The Department shall devise a means of case-managing or | ||||||
4 | patient navigation for beneficiaries diagnosed with breast | ||||||
5 | cancer. This program shall initially operate as a pilot program | ||||||
6 | in areas of the State with the highest incidence of mortality | ||||||
7 | related to breast cancer. At least one pilot program site shall | ||||||
8 | be in the metropolitan Chicago area and at least one site shall | ||||||
9 | be outside the metropolitan Chicago area. On or after July 1, | ||||||
10 | 2016, the pilot program shall be expanded to include one site | ||||||
11 | in western Illinois, one site in southern Illinois, one site in | ||||||
12 | central Illinois, and 4 sites within metropolitan Chicago. An | ||||||
13 | evaluation of the pilot program shall be carried out measuring | ||||||
14 | health outcomes and cost of care for those served by the pilot | ||||||
15 | program compared to similarly situated patients who are not | ||||||
16 | served by the pilot program. | ||||||
17 | The Department shall require all networks of care to | ||||||
18 | develop a means either internally or by contract with experts | ||||||
19 | in navigation and community outreach to navigate cancer | ||||||
20 | patients to comprehensive care in a timely fashion. The | ||||||
21 | Department shall require all networks of care to include access | ||||||
22 | for patients diagnosed with cancer to at least one academic | ||||||
23 | commission on cancer-accredited cancer program as an | ||||||
24 | in-network covered benefit. | ||||||
25 | Any medical or health care provider shall immediately | ||||||
26 | recommend, to
any pregnant woman who is being provided prenatal |
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1 | services and is suspected
of drug abuse or is addicted as | ||||||
2 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
3 | Act, referral to a local substance abuse treatment provider
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4 | licensed by the Department of Human Services or to a licensed
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5 | hospital which provides substance abuse treatment services. | ||||||
6 | The Department of Healthcare and Family Services
shall assure | ||||||
7 | coverage for the cost of treatment of the drug abuse or
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8 | addiction for pregnant recipients in accordance with the | ||||||
9 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
10 | Human Services.
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11 | All medical providers providing medical assistance to | ||||||
12 | pregnant women
under this Code shall receive information from | ||||||
13 | the Department on the
availability of services under the Drug | ||||||
14 | Free Families with a Future or any
comparable program providing | ||||||
15 | case management services for addicted women,
including | ||||||
16 | information on appropriate referrals for other social services
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17 | that may be needed by addicted women in addition to treatment | ||||||
18 | for addiction.
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19 | The Illinois Department, in cooperation with the | ||||||
20 | Departments of Human
Services (as successor to the Department | ||||||
21 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
22 | public awareness campaign, may
provide information concerning | ||||||
23 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
24 | health care, and other pertinent programs directed at
reducing | ||||||
25 | the number of drug-affected infants born to recipients of | ||||||
26 | medical
assistance.
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1 | Neither the Department of Healthcare and Family Services | ||||||
2 | nor the Department of Human
Services shall sanction the | ||||||
3 | recipient solely on the basis of
her substance abuse.
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4 | The Illinois Department shall establish such regulations | ||||||
5 | governing
the dispensing of health services under this Article | ||||||
6 | as it shall deem
appropriate. The Department
should
seek the | ||||||
7 | advice of formal professional advisory committees appointed by
| ||||||
8 | the Director of the Illinois Department for the purpose of | ||||||
9 | providing regular
advice on policy and administrative matters, | ||||||
10 | information dissemination and
educational activities for | ||||||
11 | medical and health care providers, and
consistency in | ||||||
12 | procedures to the Illinois Department.
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13 | The Illinois Department may develop and contract with | ||||||
14 | Partnerships of
medical providers to arrange medical services | ||||||
15 | for persons eligible under
Section 5-2 of this Code. | ||||||
16 | Implementation of this Section may be by
demonstration projects | ||||||
17 | in certain geographic areas. The Partnership shall
be | ||||||
18 | represented by a sponsor organization. The Department, by rule, | ||||||
19 | shall
develop qualifications for sponsors of Partnerships. | ||||||
20 | Nothing in this
Section shall be construed to require that the | ||||||
21 | sponsor organization be a
medical organization.
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22 | The sponsor must negotiate formal written contracts with | ||||||
23 | medical
providers for physician services, inpatient and | ||||||
24 | outpatient hospital care,
home health services, treatment for | ||||||
25 | alcoholism and substance abuse, and
other services determined | ||||||
26 | necessary by the Illinois Department by rule for
delivery by |
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1 | Partnerships. Physician services must include prenatal and
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2 | obstetrical care. The Illinois Department shall reimburse | ||||||
3 | medical services
delivered by Partnership providers to clients | ||||||
4 | in target areas according to
provisions of this Article and the | ||||||
5 | Illinois Health Finance Reform Act,
except that:
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6 | (1) Physicians participating in a Partnership and | ||||||
7 | providing certain
services, which shall be determined by | ||||||
8 | the Illinois Department, to persons
in areas covered by the | ||||||
9 | Partnership may receive an additional surcharge
for such | ||||||
10 | services.
| ||||||
11 | (2) The Department may elect to consider and negotiate | ||||||
12 | financial
incentives to encourage the development of | ||||||
13 | Partnerships and the efficient
delivery of medical care.
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14 | (3) Persons receiving medical services through | ||||||
15 | Partnerships may receive
medical and case management | ||||||
16 | services above the level usually offered
through the | ||||||
17 | medical assistance program.
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18 | Medical providers shall be required to meet certain | ||||||
19 | qualifications to
participate in Partnerships to ensure the | ||||||
20 | delivery of high quality medical
services. These | ||||||
21 | qualifications shall be determined by rule of the Illinois
| ||||||
22 | Department and may be higher than qualifications for | ||||||
23 | participation in the
medical assistance program. Partnership | ||||||
24 | sponsors may prescribe reasonable
additional qualifications | ||||||
25 | for participation by medical providers, only with
the prior | ||||||
26 | written approval of the Illinois Department.
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1 | Nothing in this Section shall limit the free choice of | ||||||
2 | practitioners,
hospitals, and other providers of medical | ||||||
3 | services by clients.
In order to ensure patient freedom of | ||||||
4 | choice, the Illinois Department shall
immediately promulgate | ||||||
5 | all rules and take all other necessary actions so that
provided | ||||||
6 | services may be accessed from therapeutically certified | ||||||
7 | optometrists
to the full extent of the Illinois Optometric | ||||||
8 | Practice Act of 1987 without
discriminating between service | ||||||
9 | providers.
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10 | The Department shall apply for a waiver from the United | ||||||
11 | States Health
Care Financing Administration to allow for the | ||||||
12 | implementation of
Partnerships under this Section.
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13 | The Illinois Department shall require health care | ||||||
14 | providers to maintain
records that document the medical care | ||||||
15 | and services provided to recipients
of Medical Assistance under | ||||||
16 | this Article. Such records must be retained for a period of not | ||||||
17 | less than 6 years from the date of service or as provided by | ||||||
18 | applicable State law, whichever period is longer, except that | ||||||
19 | if an audit is initiated within the required retention period | ||||||
20 | then the records must be retained until the audit is completed | ||||||
21 | and every exception is resolved. The Illinois Department shall
| ||||||
22 | require health care providers to make available, when | ||||||
23 | authorized by the
patient, in writing, the medical records in a | ||||||
24 | timely fashion to other
health care providers who are treating | ||||||
25 | or serving persons eligible for
Medical Assistance under this | ||||||
26 | Article. All dispensers of medical services
shall be required |
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1 | to maintain and retain business and professional records
| ||||||
2 | sufficient to fully and accurately document the nature, scope, | ||||||
3 | details and
receipt of the health care provided to persons | ||||||
4 | eligible for medical
assistance under this Code, in accordance | ||||||
5 | with regulations promulgated by
the Illinois Department. The | ||||||
6 | rules and regulations shall require that proof
of the receipt | ||||||
7 | of prescription drugs, dentures, prosthetic devices and
| ||||||
8 | eyeglasses by eligible persons under this Section accompany | ||||||
9 | each claim
for reimbursement submitted by the dispenser of such | ||||||
10 | medical services.
No such claims for reimbursement shall be | ||||||
11 | approved for payment by the Illinois
Department without such | ||||||
12 | proof of receipt, unless the Illinois Department
shall have put | ||||||
13 | into effect and shall be operating a system of post-payment
| ||||||
14 | audit and review which shall, on a sampling basis, be deemed | ||||||
15 | adequate by
the Illinois Department to assure that such drugs, | ||||||
16 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
17 | is being made are actually being
received by eligible | ||||||
18 | recipients. Within 90 days after September 16, 1984 (the | ||||||
19 | effective date of Public Act 83-1439), the Illinois Department | ||||||
20 | shall establish a
current list of acquisition costs for all | ||||||
21 | prosthetic devices and any
other items recognized as medical | ||||||
22 | equipment and supplies reimbursable under
this Article and | ||||||
23 | shall update such list on a quarterly basis, except that
the | ||||||
24 | acquisition costs of all prescription drugs shall be updated no
| ||||||
25 | less frequently than every 30 days as required by Section | ||||||
26 | 5-5.12.
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1 | Notwithstanding any other law to the contrary, the Illinois | ||||||
2 | Department shall, within 365 days after July 22, 2013 (the | ||||||
3 | effective date of Public Act 98-104), establish procedures to | ||||||
4 | permit skilled care facilities licensed under the Nursing Home | ||||||
5 | Care Act to submit monthly billing claims for reimbursement | ||||||
6 | purposes. Following development of these procedures, the | ||||||
7 | Department shall, by July 1, 2016, test the viability of the | ||||||
8 | new system and implement any necessary operational or | ||||||
9 | structural changes to its information technology platforms in | ||||||
10 | order to allow for the direct acceptance and payment of nursing | ||||||
11 | home claims. | ||||||
12 | Notwithstanding any other law to the contrary, the Illinois | ||||||
13 | Department shall, within 365 days after August 15, 2014 (the | ||||||
14 | effective date of Public Act 98-963), establish procedures to | ||||||
15 | permit ID/DD facilities licensed under the ID/DD Community Care | ||||||
16 | Act and MC/DD facilities licensed under the MC/DD Act to submit | ||||||
17 | monthly billing claims for reimbursement purposes. Following | ||||||
18 | development of these procedures, the Department shall have an | ||||||
19 | additional 365 days to test the viability of the new system and | ||||||
20 | to ensure that any necessary operational or structural changes | ||||||
21 | to its information technology platforms are implemented. | ||||||
22 | The Illinois Department shall require all dispensers of | ||||||
23 | medical
services, other than an individual practitioner or | ||||||
24 | group of practitioners,
desiring to participate in the Medical | ||||||
25 | Assistance program
established under this Article to disclose | ||||||
26 | all financial, beneficial,
ownership, equity, surety or other |
| |||||||
| |||||||
1 | interests in any and all firms,
corporations, partnerships, | ||||||
2 | associations, business enterprises, joint
ventures, agencies, | ||||||
3 | institutions or other legal entities providing any
form of | ||||||
4 | health care services in this State under this Article.
| ||||||
5 | The Illinois Department may require that all dispensers of | ||||||
6 | medical
services desiring to participate in the medical | ||||||
7 | assistance program
established under this Article disclose, | ||||||
8 | under such terms and conditions as
the Illinois Department may | ||||||
9 | by rule establish, all inquiries from clients
and attorneys | ||||||
10 | regarding medical bills paid by the Illinois Department, which
| ||||||
11 | inquiries could indicate potential existence of claims or liens | ||||||
12 | for the
Illinois Department.
| ||||||
13 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
14 | period and shall be conditional for one year. During the period | ||||||
15 | of conditional enrollment, the Department may
terminate the | ||||||
16 | vendor's eligibility to participate in, or may disenroll the | ||||||
17 | vendor from, the medical assistance
program without cause. | ||||||
18 | Unless otherwise specified, such termination of eligibility or | ||||||
19 | disenrollment is not subject to the
Department's hearing | ||||||
20 | process.
However, a disenrolled vendor may reapply without | ||||||
21 | penalty.
| ||||||
22 | The Department has the discretion to limit the conditional | ||||||
23 | enrollment period for vendors based upon category of risk of | ||||||
24 | the vendor. | ||||||
25 | Prior to enrollment and during the conditional enrollment | ||||||
26 | period in the medical assistance program, all vendors shall be |
| |||||||
| |||||||
1 | subject to enhanced oversight, screening, and review based on | ||||||
2 | the risk of fraud, waste, and abuse that is posed by the | ||||||
3 | category of risk of the vendor. The Illinois Department shall | ||||||
4 | establish the procedures for oversight, screening, and review, | ||||||
5 | which may include, but need not be limited to: criminal and | ||||||
6 | financial background checks; fingerprinting; license, | ||||||
7 | certification, and authorization verifications; unscheduled or | ||||||
8 | unannounced site visits; database checks; prepayment audit | ||||||
9 | reviews; audits; payment caps; payment suspensions; and other | ||||||
10 | screening as required by federal or State law. | ||||||
11 | The Department shall define or specify the following: (i) | ||||||
12 | by provider notice, the "category of risk of the vendor" for | ||||||
13 | each type of vendor, which shall take into account the level of | ||||||
14 | screening applicable to a particular category of vendor under | ||||||
15 | federal law and regulations; (ii) by rule or provider notice, | ||||||
16 | the maximum length of the conditional enrollment period for | ||||||
17 | each category of risk of the vendor; and (iii) by rule, the | ||||||
18 | hearing rights, if any, afforded to a vendor in each category | ||||||
19 | of risk of the vendor that is terminated or disenrolled during | ||||||
20 | the conditional enrollment period. | ||||||
21 | To be eligible for payment consideration, a vendor's | ||||||
22 | payment claim or bill, either as an initial claim or as a | ||||||
23 | resubmitted claim following prior rejection, must be received | ||||||
24 | by the Illinois Department, or its fiscal intermediary, no | ||||||
25 | later than 180 days after the latest date on the claim on which | ||||||
26 | medical goods or services were provided, with the following |
| |||||||
| |||||||
1 | exceptions: | ||||||
2 | (1) In the case of a provider whose enrollment is in | ||||||
3 | process by the Illinois Department, the 180-day period | ||||||
4 | shall not begin until the date on the written notice from | ||||||
5 | the Illinois Department that the provider enrollment is | ||||||
6 | complete. | ||||||
7 | (2) In the case of errors attributable to the Illinois | ||||||
8 | Department or any of its claims processing intermediaries | ||||||
9 | which result in an inability to receive, process, or | ||||||
10 | adjudicate a claim, the 180-day period shall not begin | ||||||
11 | until the provider has been notified of the error. | ||||||
12 | (3) In the case of a provider for whom the Illinois | ||||||
13 | Department initiates the monthly billing process. | ||||||
14 | (4) In the case of a provider operated by a unit of | ||||||
15 | local government with a population exceeding 3,000,000 | ||||||
16 | when local government funds finance federal participation | ||||||
17 | for claims payments. | ||||||
18 | For claims for services rendered during a period for which | ||||||
19 | a recipient received retroactive eligibility, claims must be | ||||||
20 | filed within 180 days after the Department determines the | ||||||
21 | applicant is eligible. For claims for which the Illinois | ||||||
22 | Department is not the primary payer, claims must be submitted | ||||||
23 | to the Illinois Department within 180 days after the final | ||||||
24 | adjudication by the primary payer. | ||||||
25 | In the case of long term care facilities, within 45 | ||||||
26 | calendar days of receipt by the facility of required |
| |||||||
| |||||||
1 | prescreening information, new admissions with associated | ||||||
2 | admission documents shall be submitted through the Medical | ||||||
3 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
4 | Eligibility Verification (REV) System or shall be submitted | ||||||
5 | directly to the Department of Human Services using required | ||||||
6 | admission forms. Effective September
1, 2014, admission | ||||||
7 | documents, including all prescreening
information, must be | ||||||
8 | submitted through MEDI or REV. Confirmation numbers assigned to | ||||||
9 | an accepted transaction shall be retained by a facility to | ||||||
10 | verify timely submittal. Once an admission transaction has been | ||||||
11 | completed, all resubmitted claims following prior rejection | ||||||
12 | are subject to receipt no later than 180 days after the | ||||||
13 | admission transaction has been completed. | ||||||
14 | Claims that are not submitted and received in compliance | ||||||
15 | with the foregoing requirements shall not be eligible for | ||||||
16 | payment under the medical assistance program, and the State | ||||||
17 | shall have no liability for payment of those claims. | ||||||
18 | To the extent consistent with applicable information and | ||||||
19 | privacy, security, and disclosure laws, State and federal | ||||||
20 | agencies and departments shall provide the Illinois Department | ||||||
21 | access to confidential and other information and data necessary | ||||||
22 | to perform eligibility and payment verifications and other | ||||||
23 | Illinois Department functions. This includes, but is not | ||||||
24 | limited to: information pertaining to licensure; | ||||||
25 | certification; earnings; immigration status; citizenship; wage | ||||||
26 | reporting; unearned and earned income; pension income; |
| |||||||
| |||||||
1 | employment; supplemental security income; social security | ||||||
2 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
3 | National Practitioner Data Bank (NPDB); program and agency | ||||||
4 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
5 | corporate information; and death records. | ||||||
6 | The Illinois Department shall enter into agreements with | ||||||
7 | State agencies and departments, and is authorized to enter into | ||||||
8 | agreements with federal agencies and departments, under which | ||||||
9 | such agencies and departments shall share data necessary for | ||||||
10 | medical assistance program integrity functions and oversight. | ||||||
11 | The Illinois Department shall develop, in cooperation with | ||||||
12 | other State departments and agencies, and in compliance with | ||||||
13 | applicable federal laws and regulations, appropriate and | ||||||
14 | effective methods to share such data. At a minimum, and to the | ||||||
15 | extent necessary to provide data sharing, the Illinois | ||||||
16 | Department shall enter into agreements with State agencies and | ||||||
17 | departments, and is authorized to enter into agreements with | ||||||
18 | federal agencies and departments, including but not limited to: | ||||||
19 | the Secretary of State; the Department of Revenue; the | ||||||
20 | Department of Public Health; the Department of Human Services; | ||||||
21 | and the Department of Financial and Professional Regulation. | ||||||
22 | Beginning in fiscal year 2013, the Illinois Department | ||||||
23 | shall set forth a request for information to identify the | ||||||
24 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
25 | claims system with the goals of streamlining claims processing | ||||||
26 | and provider reimbursement, reducing the number of pending or |
| |||||||
| |||||||
1 | rejected claims, and helping to ensure a more transparent | ||||||
2 | adjudication process through the utilization of: (i) provider | ||||||
3 | data verification and provider screening technology; and (ii) | ||||||
4 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
5 | post-adjudicated predictive modeling with an integrated case | ||||||
6 | management system with link analysis. Such a request for | ||||||
7 | information shall not be considered as a request for proposal | ||||||
8 | or as an obligation on the part of the Illinois Department to | ||||||
9 | take any action or acquire any products or services. | ||||||
10 | The Illinois Department shall establish policies, | ||||||
11 | procedures,
standards and criteria by rule for the acquisition, | ||||||
12 | repair and replacement
of orthotic and prosthetic devices and | ||||||
13 | durable medical equipment. Such
rules shall provide, but not be | ||||||
14 | limited to, the following services: (1)
immediate repair or | ||||||
15 | replacement of such devices by recipients; and (2) rental, | ||||||
16 | lease, purchase or lease-purchase of
durable medical equipment | ||||||
17 | in a cost-effective manner, taking into
consideration the | ||||||
18 | recipient's medical prognosis, the extent of the
recipient's | ||||||
19 | needs, and the requirements and costs for maintaining such
| ||||||
20 | equipment. Subject to prior approval, such rules shall enable a | ||||||
21 | recipient to temporarily acquire and
use alternative or | ||||||
22 | substitute devices or equipment pending repairs or
| ||||||
23 | replacements of any device or equipment previously authorized | ||||||
24 | for such
recipient by the Department. Notwithstanding any | ||||||
25 | provision of Section 5-5f to the contrary, the Department may, | ||||||
26 | by rule, exempt certain replacement wheelchair parts from prior |
| |||||||
| |||||||
1 | approval and, for wheelchairs, wheelchair parts, wheelchair | ||||||
2 | accessories, and related seating and positioning items, | ||||||
3 | determine the wholesale price by methods other than actual | ||||||
4 | acquisition costs. | ||||||
5 | The Department shall require, by rule, all providers of | ||||||
6 | durable medical equipment to be accredited by an accreditation | ||||||
7 | organization approved by the federal Centers for Medicare and | ||||||
8 | Medicaid Services and recognized by the Department in order to | ||||||
9 | bill the Department for providing durable medical equipment to | ||||||
10 | recipients. No later than 15 months after the effective date of | ||||||
11 | the rule adopted pursuant to this paragraph, all providers must | ||||||
12 | meet the accreditation requirement.
| ||||||
13 | The Department shall execute, relative to the nursing home | ||||||
14 | prescreening
project, written inter-agency agreements with the | ||||||
15 | Department of Human
Services and the Department on Aging, to | ||||||
16 | effect the following: (i) intake
procedures and common | ||||||
17 | eligibility criteria for those persons who are receiving
| ||||||
18 | non-institutional services; and (ii) the establishment and | ||||||
19 | development of
non-institutional services in areas of the State | ||||||
20 | where they are not currently
available or are undeveloped; and | ||||||
21 | (iii) notwithstanding any other provision of law, subject to | ||||||
22 | federal approval, on and after July 1, 2012, an increase in the | ||||||
23 | determination of need (DON) scores from 29 to 37 for applicants | ||||||
24 | for institutional and home and community-based long term care; | ||||||
25 | if and only if federal approval is not granted, the Department | ||||||
26 | may, in conjunction with other affected agencies, implement |
| |||||||
| |||||||
1 | utilization controls or changes in benefit packages to | ||||||
2 | effectuate a similar savings amount for this population; and | ||||||
3 | (iv) no later than July 1, 2013, minimum level of care | ||||||
4 | eligibility criteria for institutional and home and | ||||||
5 | community-based long term care; and (v) no later than October | ||||||
6 | 1, 2013, establish procedures to permit long term care | ||||||
7 | providers access to eligibility scores for individuals with an | ||||||
8 | admission date who are seeking or receiving services from the | ||||||
9 | long term care provider. In order to select the minimum level | ||||||
10 | of care eligibility criteria, the Governor shall establish a | ||||||
11 | workgroup that includes affected agency representatives and | ||||||
12 | stakeholders representing the institutional and home and | ||||||
13 | community-based long term care interests. This Section shall | ||||||
14 | not restrict the Department from implementing lower level of | ||||||
15 | care eligibility criteria for community-based services in | ||||||
16 | circumstances where federal approval has been granted.
| ||||||
17 | The Illinois Department shall develop and operate, in | ||||||
18 | cooperation
with other State Departments and agencies and in | ||||||
19 | compliance with
applicable federal laws and regulations, | ||||||
20 | appropriate and effective
systems of health care evaluation and | ||||||
21 | programs for monitoring of
utilization of health care services | ||||||
22 | and facilities, as it affects
persons eligible for medical | ||||||
23 | assistance under this Code.
| ||||||
24 | The Illinois Department shall report annually to the | ||||||
25 | General Assembly,
no later than the second Friday in April of | ||||||
26 | 1979 and each year
thereafter, in regard to:
|
| |||||||
| |||||||
1 | (a) actual statistics and trends in utilization of | ||||||
2 | medical services by
public aid recipients;
| ||||||
3 | (b) actual statistics and trends in the provision of | ||||||
4 | the various medical
services by medical vendors;
| ||||||
5 | (c) current rate structures and proposed changes in | ||||||
6 | those rate structures
for the various medical vendors; and
| ||||||
7 | (d) efforts at utilization review and control by the | ||||||
8 | Illinois Department.
| ||||||
9 | The period covered by each report shall be the 3 years | ||||||
10 | ending on the June
30 prior to the report. The report shall | ||||||
11 | include suggested legislation
for consideration by the General | ||||||
12 | Assembly. The filing of one copy of the
report with the | ||||||
13 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
14 | the Clerk of the House of Representatives, one copy with the | ||||||
15 | President,
one copy with the Minority Leader and one copy with | ||||||
16 | the Secretary of the
Senate, one copy with the Legislative | ||||||
17 | Research Unit, and such additional
copies
with the State | ||||||
18 | Government Report Distribution Center for the General
Assembly | ||||||
19 | as is required under paragraph (t) of Section 7 of the State
| ||||||
20 | Library Act shall be deemed sufficient to comply with this | ||||||
21 | Section.
| ||||||
22 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
23 | any, is conditioned on the rules being adopted in accordance | ||||||
24 | with all provisions of the Illinois Administrative Procedure | ||||||
25 | Act and all rules and procedures of the Joint Committee on | ||||||
26 | Administrative Rules; any purported rule not so adopted, for |
| |||||||
| |||||||
1 | whatever reason, is unauthorized. | ||||||
2 | On and after July 1, 2012, the Department shall reduce any | ||||||
3 | rate of reimbursement for services or other payments or alter | ||||||
4 | any methodologies authorized by this Code to reduce any rate of | ||||||
5 | reimbursement for services or other payments in accordance with | ||||||
6 | Section 5-5e. | ||||||
7 | Because kidney transplantation can be an appropriate, cost | ||||||
8 | effective
alternative to renal dialysis when medically | ||||||
9 | necessary and notwithstanding the provisions of Section 1-11 of | ||||||
10 | this Code, beginning October 1, 2014, the Department shall | ||||||
11 | cover kidney transplantation for noncitizens with end-stage | ||||||
12 | renal disease who are not eligible for comprehensive medical | ||||||
13 | benefits, who meet the residency requirements of Section 5-3 of | ||||||
14 | this Code, and who would otherwise meet the financial | ||||||
15 | requirements of the appropriate class of eligible persons under | ||||||
16 | Section 5-2 of this Code. To qualify for coverage of kidney | ||||||
17 | transplantation, such person must be receiving emergency renal | ||||||
18 | dialysis services covered by the Department. Providers under | ||||||
19 | this Section shall be prior approved and certified by the | ||||||
20 | Department to perform kidney transplantation and the services | ||||||
21 | under this Section shall be limited to services associated with | ||||||
22 | kidney transplantation. | ||||||
23 | Notwithstanding any other provision of this Code to the | ||||||
24 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
25 | medication assisted treatment prescribed for the treatment of | ||||||
26 | alcohol dependence or treatment of opioid dependence shall be |
| |||||||
| |||||||
1 | covered under both fee for service and managed care medical | ||||||
2 | assistance programs for persons who are otherwise eligible for | ||||||
3 | medical assistance under this Article and shall not be subject | ||||||
4 | to any (1) utilization control, other than those established | ||||||
5 | under the American Society of Addiction Medicine patient | ||||||
6 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
7 | lifetime restriction limit
mandate. | ||||||
8 | On or after July 1, 2015, opioid antagonists prescribed for | ||||||
9 | the treatment of an opioid overdose, including the medication | ||||||
10 | product, administration devices, and any pharmacy fees related | ||||||
11 | to the dispensing and administration of the opioid antagonist, | ||||||
12 | shall be covered under the medical assistance program for | ||||||
13 | persons who are otherwise eligible for medical assistance under | ||||||
14 | this Article. As used in this Section, "opioid antagonist" | ||||||
15 | means a drug that binds to opioid receptors and blocks or | ||||||
16 | inhibits the effect of opioids acting on those receptors, | ||||||
17 | including, but not limited to, naloxone hydrochloride or any | ||||||
18 | other similarly acting drug approved by the U.S. Food and Drug | ||||||
19 | Administration. | ||||||
20 | Upon federal approval, the Department shall provide | ||||||
21 | coverage and reimbursement for all drugs that are approved for | ||||||
22 | marketing by the federal Food and Drug Administration and that | ||||||
23 | are recommended by the federal Public Health Service or the | ||||||
24 | United States Centers for Disease Control and Prevention for | ||||||
25 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
26 | services, including, but not limited to, HIV and sexually |
| |||||||
| |||||||
1 | transmitted infection screening, treatment for sexually | ||||||
2 | transmitted infections, medical monitoring, assorted labs, and | ||||||
3 | counseling to reduce the likelihood of HIV infection among | ||||||
4 | individuals who are not infected with HIV but who are at high | ||||||
5 | risk of HIV infection. | ||||||
6 | Notwithstanding any other provision of this Code to the | ||||||
7 | contrary, on or after July
1, 2018, all FDA approved | ||||||
8 | prescription medications that are recognized by a generally | ||||||
9 | accepted
standard medical reference as effective in the | ||||||
10 | treatment of conditions specified in the most recent
Diagnostic | ||||||
11 | and Statistical Manual of Mental Disorders published by the | ||||||
12 | American Psychiatric Association
must be covered under both | ||||||
13 | fee-for-service and managed care medical assistance
programs | ||||||
14 | for persons who are otherwise eligible for medical assistance | ||||||
15 | under
this Article and shall not be subject to any (i) | ||||||
16 | utilization control, (ii) prior authorization mandate, or | ||||||
17 | (iii)
lifetime restriction limit mandate. | ||||||
18 | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | ||||||
19 | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | ||||||
20 | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | ||||||
21 | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | ||||||
22 | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | ||||||
23 | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | ||||||
24 | 100-538, eff. 1-1-18; revised 10-26-17.)".
|