Bill Text: IL HB2842 | 2013-2014 | 98th General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides for payment for ground ambulance services under the medical assistance program. Provides that for ground ambulance services provided to a medical assistance recipient on or after January 1, 2014, the Department of Healthcare and Family Services shall provide payment to ground ambulance services providers for base charges and mileage charges based upon the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule payment rates. Provides that effective January 1, 2014, the Illinois Medicaid Ambulance Fee Schedule shall be established and shall include only the ground ambulance services payment rates outlined in the Medicare Ambulance Fee Schedule as promulgated by the Centers for Medicare and Medicaid Services in effect as of July 1, 2013 and adjusted for the 4 Medicare Localities in Illinois, with an adjustment of 80% of the Medicare Ambulance Fee Schedule payment rates, by Medicare Locality, for both base rates and mileage for all counties. Provides that for ground ambulance services provided where the point of pickup is in a rural county, the Department shall pay an amount equal to one and one-half times the ground mileage rate for the first 17 miles of such a transport and the ground mileage rate for the remaining miles of the transport. Makes other changes in connection with medical assistance payments for ground ambulance services. Effective July 1, 2013.

Spectrum: Bipartisan Bill

Status: (Failed) 2014-12-03 - Session Sine Die [HB2842 Detail]

Download: Illinois-2013-HB2842-Introduced.html

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98TH GENERAL ASSEMBLY State of Illinois 2013 and 2014 HB2842 Introduced , by Rep. Brandon W. Phelps SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-4.2 from Ch. 23, par. 5-4.2
305 ILCS 5/5-5 from Ch. 23, par. 5-5
Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides for payment for ground ambulance services under the medical assistance program. Provides that for ground ambulance services provided to a medical assistance recipient on or after January 1, 2014, the Department of Healthcare and Family Services shall provide payment to ground ambulance services providers for base charges and mileage charges based upon the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule payment rates. Provides that effective January 1, 2014, the Illinois Medicaid Ambulance Fee Schedule shall be established and shall include only the ground ambulance services payment rates outlined in the Medicare Ambulance Fee Schedule as promulgated by the Centers for Medicare and Medicaid Services in effect as of July 1, 2013 and adjusted for the 4 Medicare Localities in Illinois, with an adjustment of 80% of the Medicare Ambulance Fee Schedule payment rates, by Medicare Locality, for both base rates and mileage for all counties. Provides that for ground ambulance services provided where the point of pickup is in a rural county, the Department shall pay an amount equal to one and one-half times the ground mileage rate for the first 17 miles of such a transport and the ground mileage rate for the remaining miles of the transport. Makes other changes in connection with medical assistance payments for ground ambulance services. Effective July 1, 2013.
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FISCAL NOTE ACT MAY APPLY
A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Sections 5-4.2 and 5-5 as follows:
(305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
Sec. 5-4.2. Ground ambulance Ambulance services payments.
(a) For purposes of this Section, the following terms have
the following meanings:
"Department" means the Illinois Department of Healthcare
and Family Services.
"Ground ambulance services" means medical transportation
services that are described as ground ambulance services by the
Centers for Medicare and Medicaid Services and provided in a
vehicle that is licensed as an ambulance by the Illinois
Department of Public Health pursuant to the Emergency Medical
Services (EMS) Systems Act.
"Ground ambulance services provider" means a vehicle
service provider as described in the Emergency Medical Services
(EMS) Systems Act that operates licensed ambulances for the
purpose of providing emergency ambulance services, or
non-emergency ambulance services, or both. For purposes of this
Section, this includes both ambulance providers and ambulance

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suppliers as described by the Centers for Medicare and Medicaid
Services.
"Payment principles of Medicare" means: the accepted
method propounded by the Centers for Medicare and Medicaid
Services and used to determine the payment system for ground
ambulance services providers and suppliers under Title XVIII of
the Social Security Act. These principles are outlined in the
United States Code, the Code of Federal Regulations, and the
CMS Online Manual System, including, but not limited to, the
Medicare Benefit Policy Manual and the Medicare Claims
Processing Manual, and include the statutes, regulations,
policies, procedures, definitions, guidelines, and coding
systems, including the Health Care Common Procedure Coding
System (HCPCS) and ambulance condition coding system, as well
as other resources which have been or will be developed and
recognized by the Centers for Medicare and Medicaid Services.
"Rural county" means: any county not located in a U.S.
Bureau of the Census Metropolitan Statistical Area (MSA); or
any county located within a U.S. Bureau of the Census
Metropolitan Statistical Area but having a population of 60,000
or less.
(b) It is the intent of the General Assembly to provide for
the payment for ground ambulance services as part of the State
Medicaid plan and to provide adequate payment for ground
ambulance services under the State Medicaid plan so as to
ensure adequate access to ground ambulance services for both

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recipients of aid under this Article and for the general
population of Illinois. Unless otherwise indicated in this
Section, the practices of the Department concerning payments
for ground ambulance services provided to recipients of aid
under this Article shall be consistent with the payment
principles of Medicare.
(c) For ground ambulance services provided to a recipient
of aid under this Article on or after January 1, 2014, the
Department shall provide payment to ground ambulance services
providers for base charges and mileage charges based upon the
lesser of the provider's charge, as reflected on the provider's
claim form, or the Illinois Medicaid Ambulance Fee Schedule
payment rates calculated in accordance with this Section.
Effective January 1, 2014, the Illinois Medicaid Ambulance
Fee Schedule shall be established and shall include only the
ground ambulance services payment rates outlined in the
Medicare Ambulance Fee Schedule as promulgated by the Centers
for Medicare and Medicaid Services in effect as of July 1, 2013
and adjusted for the 4 Medicare Localities in Illinois, with an
adjustment of 80% of the Medicare Ambulance Fee Schedule
payment rates, by Medicare Locality, for both base rates and
mileage for all counties. The transition from the current
payment system to the Illinois Medicaid Ambulance Fee Schedule
shall be as follows: Effective for dates of service on or after
January 1, 2014, for each individual base rate and mileage
rate, the payment rate for ground ambulance services shall be

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based on the Illinois Medicaid Ambulance Fee Schedule amount in
effect on January 1, 2014 for the designated Medicare Locality,
except that any payment rate that was previously approved by
the Department that exceeds this amount shall remain in force.
Notwithstanding the payment principles in subsection (b)
of this Section, the Department shall develop the Illinois
Medicaid Ambulance Fee Schedule using the ground mileage
payment rate, as defined by the Centers for Medicare and
Medicaid Services. For ground ambulance services provided
where the point of pickup is in a rural county, the Department
shall pay an amount equal to one and one-half times the ground
mileage rate for the first 17 miles of such a transport and the
ground mileage rate for the remaining miles of the transport.
(d) Payment for mileage shall be per loaded mile with no
loaded mileage included in the base rate. If a natural
disaster, weather, road repairs, traffic congestion, or other
conditions necessitate a route other than the most direct
route, payment shall be based upon the actual distance
traveled. When a ground ambulance services provider provides
transport pursuant to an emergency call as defined by the
Centers for Medicare and Medicaid Services, no reduction in the
mileage payment shall be made based upon the fact that a closer
facility may have been available, so long as the ground
ambulance services provider provided transport to the
recipient's facility of choice or other appropriate facility
described within the scope of the Illinois Emergency Medical

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Services (EMS) Systems Act and associated rules or the policies
and procedures of the EMS System of which the provider is a
member.
(d-5) The Department shall provide payment for emergency
ground ambulance services provided to a recipient of aid under
this Article according to the requirements provided in
subsection (b) of this Section when those services are provided
pursuant to a request made through a 9-1-1 or equivalent
emergency telephone number for evaluation, treatment, and
transport from or on behalf of an individual with a condition
of such a nature that a prudent layperson would have reasonably
expected that a delay in seeking immediate medical attention
would have been hazardous to life or health. This standard is
deemed to be met if there is an emergency medical condition
manifesting itself by acute symptoms of sufficient severity,
including but not limited to severe pain, such that a prudent
layperson who possesses an average knowledge of medicine and
health can reasonably expect that the absence of immediate
medical attention could result in placing the health of the
individual or, with respect to a pregnant woman, the health of
the woman or her unborn child, in serious jeopardy, cause
serious impairment to bodily functions, or cause serious
dysfunction of any bodily organ or part.
(e) For ground ambulance services provided to a recipient
enrolled in a Medicaid managed care plan by a ground ambulance
services provider that is not a contracted provider to the

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Medicaid managed care plan in question, the amount of the
payment for ground ambulance services by the Medicaid managed
care plan shall be the lesser of the provider's charge, as
reflected on the provider's claim form, or the Illinois
Medicaid Ambulance Fee Schedule payment rates calculated in
accordance with this Section.
(f) Nothing in this Section prohibits the Department from
setting payment rates for out-of-State ground ambulance
services providers by administrative rule.
(f-1) Nothing in this Section prohibits the Department from
setting payment rates for ground ambulance services providers
by administrative rule pending the availability of
appropriations dedicated to rate increases provided under
subsection (c).
(f-2) All payments under subsection (c) of this Section are
subject to the availability of appropriations for those
purposes.
(a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article and
to provide appropriate incentives to ambulance service
providers to provide services in an efficient and

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cost-effective manner. Thus, it is the intent of the General
Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the extent
practicable and subject to the availability of funds
appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to
determine the amounts paid to ambulance service providers under
Title XVIII of the Social Security Act (Medicare).
(b) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
(c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, medi-car, service car, or taxi.
(c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are

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described as ground ambulance services by the Centers for
Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)
Systems Act.
(c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as described
in the Emergency Medical Services (EMS) Systems Act that
operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described
by the Centers for Medicare and Medicaid Services.
(d) This Section does not prohibit separate billing by
ambulance service providers for oxygen furnished while
providing advanced life support services.
(f-3) (e) Beginning with services rendered on or after July
1, 2008, all providers of non-emergency medi-car and service
car transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must
maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or its
representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the

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Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually
transported the patient. Providers must recertify all drivers
and employee attendants every 3 years.
Notwithstanding the requirements above, any public
transportation provider of medi-car and service car
transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is already
federally mandated.
(f-4) (f) With respect to any policy or program
administered by the Department or its agent regarding approval
of non-emergency medical transportation by ground ambulance
service providers, including, but not limited to, the
Non-Emergency Transportation Services Prior Approval Program
(NETSPAP), the Department shall establish by rule a process by
which ground ambulance service providers of non-emergency
medical transportation may appeal any decision by the
Department or its agent for which no denial was received prior
to the time of transport that either (i) denies a request for
approval for payment of non-emergency transportation by means
of ground ambulance service or (ii) grants a request for
approval of non-emergency transportation by means of ground
ambulance service at a level of service that entitles the

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ground ambulance service provider to a lower level of
compensation from the Department than the ground ambulance
service provider would have received as compensation for the
level of service requested. The rule shall be filed by December
15, 2012 and shall provide that, for any decision rendered by
the Department or its agent on or after the date the rule takes
effect, the ground ambulance service provider shall have 60
days from the date the decision is received to file an appeal.
The rule established by the Department shall be, insofar as is
practical, consistent with the Illinois Administrative
Procedure Act. The Director's decision on an appeal under this
Section shall be a final administrative decision subject to
review under the Administrative Review Law.
(f-5) (g) Beginning 90 days after July 20, 2012 (the
effective date of Public Act 97-842) this amendatory Act of the
97th General Assembly, (i) no denial of a request for approval
for payment of non-emergency transportation by means of ground
ambulance service, and (ii) no approval of non-emergency
transportation by means of ground ambulance service at a level
of service that entitles the ground ambulance service provider
to a lower level of compensation from the Department than would
have been received at the level of service submitted by the
ground ambulance service provider, may be issued by the
Department or its agent unless the Department has submitted the
criteria for determining the appropriateness of the transport
for first notice publication in the Illinois Register pursuant

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to Section 5-40 of the Illinois Administrative Procedure Act.
(g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program
administered by the Department is being discharged from a
facility, a physician discharge order as described in this
Section shall be required for each patient whose discharge
requires medically supervised ground ambulance services.
Facilities shall develop procedures for a physician with
medical staff privileges to provide a written and signed
physician discharge order. The physician discharge order shall
specify the level of ground ambulance services needed and
complete a medical certification establishing the criteria for
approval of non-emergency ambulance transportation, as
published by the Department of Healthcare and Family Services,
that is met by the patient. This order and the medical
certification shall be completed prior to ordering an ambulance
service and prior to patient discharge.
Pursuant to subsection (E) of Section 12-4.25 of this Code,
the Department is entitled to recover overpayments paid to a
provider or vendor, including, but not limited to, from the
discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
(h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or

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alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12;
97-842, eff. 7-20-12; revised 8-3-12.)
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial
care furnished by licensed practitioners; (7) home health care
services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for
pregnant women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy

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and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services, including
to ensure that the individual's need for intervention or
treatment of mental disorders or substance use disorders or
co-occurring mental health and substance use disorders is
determined using a uniform screening, assessment, and
evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary,
provided that payment for ground ambulance services shall be as
provided in Section 5-4.2; (15) medical treatment of sexual
assault survivors, as defined in Section 1a of the Sexual
Assault Survivors Emergency Treatment Act, for injuries
sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which
may be used in criminal proceedings arising from the sexual
assault; (16) the diagnosis and treatment of sickle cell
anemia; and (17) any other medical care, and any other type of
remedial care recognized under the laws of this State, but not

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including abortions, or induced miscarriages or premature
births, unless, in the opinion of a physician, such procedures
are necessary for the preservation of the life of the woman
seeking such treatment, or except an induced premature birth
intended to produce a live viable child and such procedure is
necessary for the health of the mother or her unborn child. The
Illinois Department, by rule, shall prohibit any physician from
providing medical assistance to anyone eligible therefor under
this Code where such physician has been found guilty of
performing an abortion procedure in a wilful and wanton manner
upon a woman who was not pregnant at the time such abortion
procedure was performed. The term "any other type of remedial
care" shall include nursing care and nursing home service for
persons who rely on treatment by spiritual means alone through
prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory

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test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
On and after July 1, 2012, the Department of Healthcare and
Family Services may provide the following services to persons
eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in the
diseases of the eye, or by an optometrist, whichever the
person may select.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical assistance
program. A not-for-profit health clinic shall include a public
health clinic or Federally Qualified Health Center or other
enrolled provider, as determined by the Department, through
which dental services covered under this Section are performed.
The Department shall establish a process for payment of claims
for reimbursement for covered dental services rendered under

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this provision.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
(A) A baseline mammogram for women 35 to 39 years of
age.
(B) An annual mammogram for women 40 years of age or
older.
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for
women under 40 years of age and having a family history of
breast cancer, prior personal history of breast cancer,
positive genetic testing, or other risk factors.
(D) A comprehensive ultrasound screening of an entire

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breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue, when medically
necessary as determined by a physician licensed to practice
medicine in all of its branches.
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool. For purposes of this Section, "low-dose mammography"
means the x-ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray
tube, filter, compression device, and image receptor, with an
average radiation exposure delivery of less than one rad per
breast for 2 views of an average size breast. The term also
includes digital mammography.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall be
reimbursed for screening and diagnostic mammography at the same
rate as the Medicare program's rates, including the increased
reimbursement for digital mammography.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.

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These clinics or centers may also collaborate with other
hospital-based mammography facilities.
The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening mammography.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot program
in areas of the State with the highest incidence of mortality
related to breast cancer. At least one pilot program site shall
be in the metropolitan Chicago area and at least one site shall
be outside the metropolitan Chicago area. An evaluation of the
pilot program shall be carried out measuring health outcomes
and cost of care for those served by the pilot program compared
to similarly situated patients who are not served by the pilot
program.
Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided prenatal
services and is suspected of drug abuse or is addicted as

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defined in the Alcoholism and Other Drug Abuse and Dependency
Act, referral to a local substance abuse treatment provider
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department of
Human Services.
All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free Families with a Future or any comparable program providing
case management services for addicted women, including
information on appropriate referrals for other social services
that may be needed by addicted women in addition to treatment
for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through a
public awareness campaign, may provide information concerning
treatment for alcoholism and drug abuse and addiction, prenatal
health care, and other pertinent programs directed at reducing
the number of drug-affected infants born to recipients of
medical assistance.
Neither the Department of Healthcare and Family Services

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nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and

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obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by the
Partnership may receive an additional surcharge for such
services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of

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practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified
optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. Such records must be retained for a period of not
less than 6 years from the date of service or as provided by
applicable State law, whichever period is longer, except that
if an audit is initiated within the required retention period
then the records must be retained until the audit is completed
and every exception is resolved. The Illinois Department shall
require health care providers to make available, when
authorized by the patient, in writing, the medical records in a
timely fashion to other health care providers who are treating
or serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be required
to maintain and retain business and professional records

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sufficient to fully and accurately document the nature, scope,
details and receipt of the health care provided to persons
eligible for medical assistance under this Code, in accordance
with regulations promulgated by the Illinois Department. The
rules and regulations shall require that proof of the receipt
of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be
approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after the effective date of this
amendatory Act of 1984, the Illinois Department shall establish
a current list of acquisition costs for all prosthetic devices
and any other items recognized as medical equipment and
supplies reimbursable under this Article and shall update such
list on a quarterly basis, except that the acquisition costs of
all prescription drugs shall be updated no less frequently than
every 30 days as required by Section 5-5.12.
The rules and regulations of the Illinois Department shall
require that a written statement including the required opinion

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of a physician shall accompany any claim for reimbursement for
abortions, or induced miscarriages or premature births. This
statement shall indicate what procedures were used in providing
such medical services.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens
for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the period
of conditional enrollment, the Department may terminate the
vendor's eligibility to participate in, or may disenroll the
vendor from, the medical assistance program without cause.

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Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the

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hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois

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Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, admission
documents shall be submitted within 30 days of an admission to
the facility through the Medical Electronic Data Interchange
(MEDI) or the Recipient Eligibility Verification (REV) System,
or shall be submitted directly to the Department of Human
Services using required admission forms. Confirmation numbers
assigned to an accepted transaction shall be retained by a
facility to verify timely submittal. Once an admission
transaction has been completed, all resubmitted claims
following prior rejection are subject to receipt no later than
180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data necessary
to perform eligibility and payment verifications and other
Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage

HB2842 - 28 - LRB098 10757 KTG 41116 b
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.
The Illinois Department shall develop, in cooperation with
other State departments and agencies, and in compliance with
applicable federal laws and regulations, appropriate and
effective methods to share such data. At a minimum, and to the
extent necessary to provide data sharing, the Illinois
Department shall enter into agreements with State agencies and
departments, and is authorized to enter into agreements with
federal agencies and departments, including but not limited to:
the Secretary of State; the Department of Revenue; the
Department of Public Health; the Department of Human Services;
and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing

HB2842 - 29 - LRB098 10757 KTG 41116 b
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients; and (2) rental,
lease, purchase or lease-purchase of durable medical equipment
in a cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a
recipient to temporarily acquire and use alternative or
substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department.
The Department shall execute, relative to the nursing home

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prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped; and
(iii) notwithstanding any other provision of law, subject to
federal approval, on and after July 1, 2012, an increase in the
determination of need (DON) scores from 29 to 37 for applicants
for institutional and home and community-based long term care;
if and only if federal approval is not granted, the Department
may, in conjunction with other affected agencies, implement
utilization controls or changes in benefit packages to
effectuate a similar savings amount for this population; and
(iv) no later than July 1, 2013, minimum level of care
eligibility criteria for institutional and home and
community-based long term care. In order to select the minimum
level of care eligibility criteria, the Governor shall
establish a workgroup that includes affected agency
representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.

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The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The filing of one copy of the report with the
Speaker, one copy with the Minority Leader and one copy with
the Clerk of the House of Representatives, one copy with the
President, one copy with the Minority Leader and one copy with
the Secretary of the Senate, one copy with the Legislative

HB2842 - 32 - LRB098 10757 KTG 41116 b
Research Unit, and such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act shall be deemed sufficient to comply with this
Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12;
revised 9-20-12.)
Section 99. Effective date. This Act takes effect July 1,
2013.