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| 1 | AN ACT concerning public aid.
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| 2 | Be it enacted by the People of the State of Illinois,
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| 3 | represented in the General Assembly:
| |||||||||||||||||||
| 4 | Section 5. The Illinois Public Aid Code is amended by | |||||||||||||||||||
| 5 | changing Section 5-5 as follows:
| |||||||||||||||||||
| 6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| |||||||||||||||||||
| 7 | Sec. 5-5. Medical services. The Illinois Department, by | |||||||||||||||||||
| 8 | rule, shall
determine the quantity and quality of and the rate | |||||||||||||||||||
| 9 | of reimbursement for the
medical assistance for which
payment | |||||||||||||||||||
| 10 | will be authorized, and the medical services to be provided,
| |||||||||||||||||||
| 11 | which may include all or part of the following: (1) inpatient | |||||||||||||||||||
| 12 | hospital
services; (2) outpatient hospital services; (3) other | |||||||||||||||||||
| 13 | laboratory and
X-ray services; (4) skilled nursing home | |||||||||||||||||||
| 14 | services; (5) physicians'
services whether furnished in the | |||||||||||||||||||
| 15 | office, the patient's home, a
hospital, a skilled nursing | |||||||||||||||||||
| 16 | home, or elsewhere; (6) medical care, or any
other type of | |||||||||||||||||||
| 17 | remedial care furnished by licensed practitioners; (7)
home | |||||||||||||||||||
| 18 | health care services; (8) private duty nursing service; (9) | |||||||||||||||||||
| 19 | clinic
services; (10) dental services, including prevention | |||||||||||||||||||
| 20 | and treatment of periodontal disease and dental caries disease | |||||||||||||||||||
| 21 | for pregnant individuals, provided by an individual licensed | |||||||||||||||||||
| 22 | to practice dentistry or dental surgery; for purposes of this | |||||||||||||||||||
| 23 | item (10), "dental services" means diagnostic, preventive, or | |||||||||||||||||||
| |||||||
| |||||||
| 1 | corrective procedures provided by or under the supervision of | ||||||
| 2 | a dentist in the practice of his or her profession; (11) | ||||||
| 3 | physical therapy and related
services; (12) prescribed drugs, | ||||||
| 4 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
| 5 | a physician skilled in the diseases of the eye,
or by an | ||||||
| 6 | optometrist, whichever the person may select; (13) other
| ||||||
| 7 | diagnostic, screening, preventive, and rehabilitative | ||||||
| 8 | services, including to ensure that the individual's need for | ||||||
| 9 | intervention or treatment of mental disorders or substance use | ||||||
| 10 | disorders or co-occurring mental health and substance use | ||||||
| 11 | disorders is determined using a uniform screening, assessment, | ||||||
| 12 | and evaluation process inclusive of criteria, for children and | ||||||
| 13 | adults; for purposes of this item (13), a uniform screening, | ||||||
| 14 | assessment, and evaluation process refers to a process that | ||||||
| 15 | includes an appropriate evaluation and, as warranted, a | ||||||
| 16 | referral; "uniform" does not mean the use of a singular | ||||||
| 17 | instrument, tool, or process that all must utilize; (14)
| ||||||
| 18 | transportation and such other expenses as may be necessary; | ||||||
| 19 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
| 20 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
| 21 | Treatment Act, for
injuries sustained as a result of the | ||||||
| 22 | sexual assault, including
examinations and laboratory tests to | ||||||
| 23 | discover evidence which may be used in
criminal proceedings | ||||||
| 24 | arising from the sexual assault; (16) the
diagnosis and | ||||||
| 25 | treatment of sickle cell anemia; (16.5) services performed by | ||||||
| 26 | a chiropractic physician licensed under the Medical Practice | ||||||
| |||||||
| |||||||
| 1 | Act of 1987 and acting within the scope of his or her license, | ||||||
| 2 | including, but not limited to, chiropractic manipulative | ||||||
| 3 | treatment; and (17)
any other medical care, and any other type | ||||||
| 4 | of remedial care recognized
under the laws of this State. The | ||||||
| 5 | term "any other type of remedial care" shall
include nursing | ||||||
| 6 | care and nursing home service for persons who rely on
| ||||||
| 7 | treatment by spiritual means alone through prayer for healing.
| ||||||
| 8 | Notwithstanding any other provision of this Section, a | ||||||
| 9 | comprehensive
tobacco use cessation program that includes | ||||||
| 10 | purchasing prescription drugs or
prescription medical devices | ||||||
| 11 | approved by the Food and Drug Administration shall
be covered | ||||||
| 12 | under the medical assistance
program under this Article for | ||||||
| 13 | persons who are otherwise eligible for
assistance under this | ||||||
| 14 | Article.
| ||||||
| 15 | Notwithstanding any other provision of this Code, | ||||||
| 16 | reproductive health care that is otherwise legal in Illinois | ||||||
| 17 | shall be covered under the medical assistance program for | ||||||
| 18 | persons who are otherwise eligible for medical assistance | ||||||
| 19 | under this Article. | ||||||
| 20 | Notwithstanding any other provision of this Section, all | ||||||
| 21 | tobacco cessation medications approved by the United States | ||||||
| 22 | Food and Drug Administration and all individual and group | ||||||
| 23 | tobacco cessation counseling services and telephone-based | ||||||
| 24 | counseling services and tobacco cessation medications provided | ||||||
| 25 | through the Illinois Tobacco Quitline shall be covered under | ||||||
| 26 | the medical assistance program for persons who are otherwise | ||||||
| |||||||
| |||||||
| 1 | eligible for assistance under this Article. The Department | ||||||
| 2 | shall comply with all federal requirements necessary to obtain | ||||||
| 3 | federal financial participation, as specified in 42 CFR | ||||||
| 4 | 433.15(b)(7), for telephone-based counseling services provided | ||||||
| 5 | through the Illinois Tobacco Quitline, including, but not | ||||||
| 6 | limited to: (i) entering into a memorandum of understanding or | ||||||
| 7 | interagency agreement with the Department of Public Health, as | ||||||
| 8 | administrator of the Illinois Tobacco Quitline; and (ii) | ||||||
| 9 | developing a cost allocation plan for Medicaid-allowable | ||||||
| 10 | Illinois Tobacco Quitline services in accordance with 45 CFR | ||||||
| 11 | 95.507. The Department shall submit the memorandum of | ||||||
| 12 | understanding or interagency agreement, the cost allocation | ||||||
| 13 | plan, and all other necessary documentation to the Centers for | ||||||
| 14 | Medicare and Medicaid Services for review and approval. | ||||||
| 15 | Coverage under this paragraph shall be contingent upon federal | ||||||
| 16 | approval. | ||||||
| 17 | Notwithstanding any other provision of this Code, the | ||||||
| 18 | Illinois
Department may not require, as a condition of payment | ||||||
| 19 | for any laboratory
test authorized under this Article, that a | ||||||
| 20 | physician's handwritten signature
appear on the laboratory | ||||||
| 21 | test order form. The Illinois Department may,
however, impose | ||||||
| 22 | other appropriate requirements regarding laboratory test
order | ||||||
| 23 | documentation.
| ||||||
| 24 | Upon receipt of federal approval of an amendment to the | ||||||
| 25 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
| 26 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
| |||||||
| |||||||
| 1 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
| 2 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
| 3 | that its vendor or vendors are enrolled as providers in the | ||||||
| 4 | medical assistance program and in any capitated Medicaid | ||||||
| 5 | managed care entity (MCE) serving individuals enrolled in a | ||||||
| 6 | school within the CPS system. Under any contract procured | ||||||
| 7 | under this provision, the vendor or vendors must serve only | ||||||
| 8 | individuals enrolled in a school within the CPS system. Claims | ||||||
| 9 | for services provided by CPS's vendor or vendors to recipients | ||||||
| 10 | of benefits in the medical assistance program under this Code, | ||||||
| 11 | the Children's Health Insurance Program, or the Covering ALL | ||||||
| 12 | KIDS Health Insurance Program shall be submitted to the | ||||||
| 13 | Department or the MCE in which the individual is enrolled for | ||||||
| 14 | payment and shall be reimbursed at the Department's or the | ||||||
| 15 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
| 16 | On and after July 1, 2012, the Department of Healthcare | ||||||
| 17 | and Family Services may provide the following services to
| ||||||
| 18 | persons
eligible for assistance under this Article who are | ||||||
| 19 | participating in
education, training or employment programs | ||||||
| 20 | operated by the Department of Human
Services as successor to | ||||||
| 21 | the Department of Public Aid:
| ||||||
| 22 | (1) dental services provided by or under the | ||||||
| 23 | supervision of a dentist; and
| ||||||
| 24 | (2) eyeglasses prescribed by a physician skilled in | ||||||
| 25 | the diseases of the
eye, or by an optometrist, whichever | ||||||
| 26 | the person may select.
| ||||||
| |||||||
| |||||||
| 1 | On and after July 1, 2018, the Department of Healthcare | ||||||
| 2 | and Family Services shall provide dental services to any adult | ||||||
| 3 | who is otherwise eligible for assistance under the medical | ||||||
| 4 | assistance program. As used in this paragraph, "dental | ||||||
| 5 | services" means diagnostic, preventative, restorative, or | ||||||
| 6 | corrective procedures, including procedures and services for | ||||||
| 7 | the prevention and treatment of periodontal disease and dental | ||||||
| 8 | caries disease, provided by an individual who is licensed to | ||||||
| 9 | practice dentistry or dental surgery or who is under the | ||||||
| 10 | supervision of a dentist in the practice of his or her | ||||||
| 11 | profession. | ||||||
| 12 | On and after July 1, 2018, targeted dental services, as | ||||||
| 13 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
| 14 | United States District Court for the Northern District of | ||||||
| 15 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
| 16 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
| 17 | the medical assistance program shall be established at no less | ||||||
| 18 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
| 19 | of the Consent Decree for targeted dental services that are | ||||||
| 20 | provided to persons under the age of 18 under the medical | ||||||
| 21 | assistance program. | ||||||
| 22 | Notwithstanding any other provision of this Code and | ||||||
| 23 | subject to federal approval, the Department may adopt rules to | ||||||
| 24 | allow a dentist who is volunteering his or her service at no | ||||||
| 25 | cost to render dental services through an enrolled | ||||||
| 26 | not-for-profit health clinic without the dentist personally | ||||||
| |||||||
| |||||||
| 1 | enrolling as a participating provider in the medical | ||||||
| 2 | assistance program. A not-for-profit health clinic shall | ||||||
| 3 | include a public health clinic or Federally Qualified Health | ||||||
| 4 | Center or other enrolled provider, as determined by the | ||||||
| 5 | Department, through which dental services covered under this | ||||||
| 6 | Section are performed. The Department shall establish a | ||||||
| 7 | process for payment of claims for reimbursement for covered | ||||||
| 8 | dental services rendered under this provision. | ||||||
| 9 | On and after January 1, 2022, the Department of Healthcare | ||||||
| 10 | and Family Services shall administer and regulate a | ||||||
| 11 | school-based dental program that allows for the out-of-office | ||||||
| 12 | delivery of preventative dental services in a school setting | ||||||
| 13 | to children under 19 years of age. The Department shall | ||||||
| 14 | establish, by rule, guidelines for participation by providers | ||||||
| 15 | and set requirements for follow-up referral care based on the | ||||||
| 16 | requirements established in the Dental Office Reference Manual | ||||||
| 17 | published by the Department that establishes the requirements | ||||||
| 18 | for dentists participating in the All Kids Dental School | ||||||
| 19 | Program. Every effort shall be made by the Department when | ||||||
| 20 | developing the program requirements to consider the different | ||||||
| 21 | geographic differences of both urban and rural areas of the | ||||||
| 22 | State for initial treatment and necessary follow-up care. No | ||||||
| 23 | provider shall be charged a fee by any unit of local government | ||||||
| 24 | to participate in the school-based dental program administered | ||||||
| 25 | by the Department. Nothing in this paragraph shall be | ||||||
| 26 | construed to limit or preempt a home rule unit's or school | ||||||
| |||||||
| |||||||
| 1 | district's authority to establish, change, or administer a | ||||||
| 2 | school-based dental program in addition to, or independent of, | ||||||
| 3 | the school-based dental program administered by the | ||||||
| 4 | Department. | ||||||
| 5 | The Illinois Department, by rule, may distinguish and | ||||||
| 6 | classify the
medical services to be provided only in | ||||||
| 7 | accordance with the classes of
persons designated in Section | ||||||
| 8 | 5-2.
| ||||||
| 9 | The Department of Healthcare and Family Services must | ||||||
| 10 | provide coverage and reimbursement for amino acid-based | ||||||
| 11 | elemental formulas, regardless of delivery method, for the | ||||||
| 12 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
| 13 | short bowel syndrome when the prescribing physician has issued | ||||||
| 14 | a written order stating that the amino acid-based elemental | ||||||
| 15 | formula is medically necessary.
| ||||||
| 16 | The Illinois Department shall authorize the provision of, | ||||||
| 17 | and shall
authorize payment for, screening by low-dose | ||||||
| 18 | mammography for the presence of
occult breast cancer for | ||||||
| 19 | individuals 35 years of age or older who are eligible
for | ||||||
| 20 | medical assistance under this Article, as follows: | ||||||
| 21 | (A) A baseline
mammogram for individuals 35 to 39 | ||||||
| 22 | years of age.
| ||||||
| 23 | (B) An annual mammogram for individuals 40 years of | ||||||
| 24 | age or older. | ||||||
| 25 | (C) A mammogram at the age and intervals considered | ||||||
| 26 | medically necessary by the individual's health care | ||||||
| |||||||
| |||||||
| 1 | provider for individuals under 40 years of age and having | ||||||
| 2 | a family history of breast cancer, prior personal history | ||||||
| 3 | of breast cancer, positive genetic testing, or other risk | ||||||
| 4 | factors. | ||||||
| 5 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
| 6 | entire breast or breasts if a mammogram demonstrates | ||||||
| 7 | heterogeneous or dense breast tissue or when medically | ||||||
| 8 | necessary as determined by a physician licensed to | ||||||
| 9 | practice medicine in all of its branches. | ||||||
| 10 | (E) A screening MRI when medically necessary, as | ||||||
| 11 | determined by a physician licensed to practice medicine in | ||||||
| 12 | all of its branches. | ||||||
| 13 | (F) A diagnostic mammogram when medically necessary, | ||||||
| 14 | as determined by a physician licensed to practice medicine | ||||||
| 15 | in all its branches, advanced practice registered nurse, | ||||||
| 16 | or physician assistant. | ||||||
| 17 | The Department shall not impose a deductible, coinsurance, | ||||||
| 18 | copayment, or any other cost-sharing requirement on the | ||||||
| 19 | coverage provided under this paragraph; except that this | ||||||
| 20 | sentence does not apply to coverage of diagnostic mammograms | ||||||
| 21 | to the extent such coverage would disqualify a high-deductible | ||||||
| 22 | health plan from eligibility for a health savings account | ||||||
| 23 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
| 24 | U.S.C. 223). | ||||||
| 25 | All screenings
shall
include a physical breast exam, | ||||||
| 26 | instruction on self-examination and
information regarding the | ||||||
| |||||||
| |||||||
| 1 | frequency of self-examination and its value as a
preventative | ||||||
| 2 | tool. | ||||||
| 3 | For purposes of this Section: | ||||||
| 4 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
| 5 | diagnostic mammography. | ||||||
| 6 | "Diagnostic
mammography" means a method of screening that | ||||||
| 7 | is designed to
evaluate an abnormality in a breast, including | ||||||
| 8 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
| 9 | subjective or objective
abnormality otherwise detected in the | ||||||
| 10 | breast. | ||||||
| 11 | "Low-dose mammography" means
the x-ray examination of the | ||||||
| 12 | breast using equipment dedicated specifically
for mammography, | ||||||
| 13 | including the x-ray tube, filter, compression device,
and | ||||||
| 14 | image receptor, with an average radiation exposure delivery
of | ||||||
| 15 | less than one rad per breast for 2 views of an average size | ||||||
| 16 | breast.
The term also includes digital mammography and | ||||||
| 17 | includes breast tomosynthesis. | ||||||
| 18 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
| 19 | involves the acquisition of projection images over the | ||||||
| 20 | stationary breast to produce cross-sectional digital | ||||||
| 21 | three-dimensional images of the breast. | ||||||
| 22 | If, at any time, the Secretary of the United States | ||||||
| 23 | Department of Health and Human Services, or its successor | ||||||
| 24 | agency, promulgates rules or regulations to be published in | ||||||
| 25 | the Federal Register or publishes a comment in the Federal | ||||||
| 26 | Register or issues an opinion, guidance, or other action that | ||||||
| |||||||
| |||||||
| 1 | would require the State, pursuant to any provision of the | ||||||
| 2 | Patient Protection and Affordable Care Act (Public Law | ||||||
| 3 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
| 4 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
| 5 | of any coverage for breast tomosynthesis outlined in this | ||||||
| 6 | paragraph, then the requirement that an insurer cover breast | ||||||
| 7 | tomosynthesis is inoperative other than any such coverage | ||||||
| 8 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
| 9 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
| 10 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
| 11 | this paragraph.
| ||||||
| 12 | On and after January 1, 2016, the Department shall ensure | ||||||
| 13 | that all networks of care for adult clients of the Department | ||||||
| 14 | include access to at least one breast imaging Center of | ||||||
| 15 | Imaging Excellence as certified by the American College of | ||||||
| 16 | Radiology. | ||||||
| 17 | On and after January 1, 2012, providers participating in a | ||||||
| 18 | quality improvement program approved by the Department shall | ||||||
| 19 | be reimbursed for screening and diagnostic mammography at the | ||||||
| 20 | same rate as the Medicare program's rates, including the | ||||||
| 21 | increased reimbursement for digital mammography and, after | ||||||
| 22 | January 1, 2023 (the effective date of Public Act 102-1018) | ||||||
| 23 | this amendatory Act of the 102nd General Assembly, breast | ||||||
| 24 | tomosynthesis. | ||||||
| 25 | The Department shall convene an expert panel including | ||||||
| 26 | representatives of hospitals, free-standing mammography | ||||||
| |||||||
| |||||||
| 1 | facilities, and doctors, including radiologists, to establish | ||||||
| 2 | quality standards for mammography. | ||||||
| 3 | On and after January 1, 2017, providers participating in a | ||||||
| 4 | breast cancer treatment quality improvement program approved | ||||||
| 5 | by the Department shall be reimbursed for breast cancer | ||||||
| 6 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
| 7 | program's rates for the data elements included in the breast | ||||||
| 8 | cancer treatment quality program. | ||||||
| 9 | The Department shall convene an expert panel, including | ||||||
| 10 | representatives of hospitals, free-standing breast cancer | ||||||
| 11 | treatment centers, breast cancer quality organizations, and | ||||||
| 12 | doctors, including breast surgeons, reconstructive breast | ||||||
| 13 | surgeons, oncologists, and primary care providers to establish | ||||||
| 14 | quality standards for breast cancer treatment. | ||||||
| 15 | Subject to federal approval, the Department shall | ||||||
| 16 | establish a rate methodology for mammography at federally | ||||||
| 17 | qualified health centers and other encounter-rate clinics. | ||||||
| 18 | These clinics or centers may also collaborate with other | ||||||
| 19 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
| 20 | Department shall report to the General Assembly on the status | ||||||
| 21 | of the provision set forth in this paragraph. | ||||||
| 22 | The Department shall establish a methodology to remind | ||||||
| 23 | individuals who are age-appropriate for screening mammography, | ||||||
| 24 | but who have not received a mammogram within the previous 18 | ||||||
| 25 | months, of the importance and benefit of screening | ||||||
| 26 | mammography. The Department shall work with experts in breast | ||||||
| |||||||
| |||||||
| 1 | cancer outreach and patient navigation to optimize these | ||||||
| 2 | reminders and shall establish a methodology for evaluating | ||||||
| 3 | their effectiveness and modifying the methodology based on the | ||||||
| 4 | evaluation. | ||||||
| 5 | The Department shall establish a performance goal for | ||||||
| 6 | primary care providers with respect to their female patients | ||||||
| 7 | over age 40 receiving an annual mammogram. This performance | ||||||
| 8 | goal shall be used to provide additional reimbursement in the | ||||||
| 9 | form of a quality performance bonus to primary care providers | ||||||
| 10 | who meet that goal. | ||||||
| 11 | The Department shall devise a means of case-managing or | ||||||
| 12 | patient navigation for beneficiaries diagnosed with breast | ||||||
| 13 | cancer. This program shall initially operate as a pilot | ||||||
| 14 | program in areas of the State with the highest incidence of | ||||||
| 15 | mortality related to breast cancer. At least one pilot program | ||||||
| 16 | site shall be in the metropolitan Chicago area and at least one | ||||||
| 17 | site shall be outside the metropolitan Chicago area. On or | ||||||
| 18 | after July 1, 2016, the pilot program shall be expanded to | ||||||
| 19 | include one site in western Illinois, one site in southern | ||||||
| 20 | Illinois, one site in central Illinois, and 4 sites within | ||||||
| 21 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
| 22 | be carried out measuring health outcomes and cost of care for | ||||||
| 23 | those served by the pilot program compared to similarly | ||||||
| 24 | situated patients who are not served by the pilot program. | ||||||
| 25 | The Department shall require all networks of care to | ||||||
| 26 | develop a means either internally or by contract with experts | ||||||
| |||||||
| |||||||
| 1 | in navigation and community outreach to navigate cancer | ||||||
| 2 | patients to comprehensive care in a timely fashion. The | ||||||
| 3 | Department shall require all networks of care to include | ||||||
| 4 | access for patients diagnosed with cancer to at least one | ||||||
| 5 | academic commission on cancer-accredited cancer program as an | ||||||
| 6 | in-network covered benefit. | ||||||
| 7 | The Department shall provide coverage and reimbursement | ||||||
| 8 | for a human papillomavirus (HPV) vaccine that is approved for | ||||||
| 9 | marketing by the federal Food and Drug Administration for all | ||||||
| 10 | persons between the ages of 9 and 45 and persons of the age of | ||||||
| 11 | 46 and above who have been diagnosed with cervical dysplasia | ||||||
| 12 | with a high risk of recurrence or progression. The Department | ||||||
| 13 | shall disallow any preauthorization requirements for the | ||||||
| 14 | administration of the human papillomavirus (HPV) vaccine. | ||||||
| 15 | On or after July 1, 2022, individuals who are otherwise | ||||||
| 16 | eligible for medical assistance under this Article shall | ||||||
| 17 | receive coverage for perinatal depression screenings for the | ||||||
| 18 | 12-month period beginning on the last day of their pregnancy. | ||||||
| 19 | Medical assistance coverage under this paragraph shall be | ||||||
| 20 | conditioned on the use of a screening instrument approved by | ||||||
| 21 | the Department. | ||||||
| 22 | Any medical or health care provider shall immediately | ||||||
| 23 | recommend, to
any pregnant individual who is being provided | ||||||
| 24 | prenatal services and is suspected
of having a substance use | ||||||
| 25 | disorder as defined in the Substance Use Disorder Act, | ||||||
| 26 | referral to a local substance use disorder treatment program | ||||||
| |||||||
| |||||||
| 1 | licensed by the Department of Human Services or to a licensed
| ||||||
| 2 | hospital which provides substance abuse treatment services. | ||||||
| 3 | The Department of Healthcare and Family Services
shall assure | ||||||
| 4 | coverage for the cost of treatment of the drug abuse or
| ||||||
| 5 | addiction for pregnant recipients in accordance with the | ||||||
| 6 | Illinois Medicaid
Program in conjunction with the Department | ||||||
| 7 | of Human Services.
| ||||||
| 8 | All medical providers providing medical assistance to | ||||||
| 9 | pregnant individuals
under this Code shall receive information | ||||||
| 10 | from the Department on the
availability of services under any
| ||||||
| 11 | program providing case management services for addicted | ||||||
| 12 | individuals,
including information on appropriate referrals | ||||||
| 13 | for other social services
that may be needed by addicted | ||||||
| 14 | individuals in addition to treatment for addiction.
| ||||||
| 15 | The Illinois Department, in cooperation with the | ||||||
| 16 | Departments of Human
Services (as successor to the Department | ||||||
| 17 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
| 18 | a public awareness campaign, may
provide information | ||||||
| 19 | concerning treatment for alcoholism and drug abuse and
| ||||||
| 20 | addiction, prenatal health care, and other pertinent programs | ||||||
| 21 | directed at
reducing the number of drug-affected infants born | ||||||
| 22 | to recipients of medical
assistance.
| ||||||
| 23 | Neither the Department of Healthcare and Family Services | ||||||
| 24 | nor the Department of Human
Services shall sanction the | ||||||
| 25 | recipient solely on the basis of the recipient's
substance | ||||||
| 26 | abuse.
| ||||||
| |||||||
| |||||||
| 1 | The Illinois Department shall establish such regulations | ||||||
| 2 | governing
the dispensing of health services under this Article | ||||||
| 3 | as it shall deem
appropriate. The Department
should
seek the | ||||||
| 4 | advice of formal professional advisory committees appointed by
| ||||||
| 5 | the Director of the Illinois Department for the purpose of | ||||||
| 6 | providing regular
advice on policy and administrative matters, | ||||||
| 7 | information dissemination and
educational activities for | ||||||
| 8 | medical and health care providers, and
consistency in | ||||||
| 9 | procedures to the Illinois Department.
| ||||||
| 10 | The Illinois Department may develop and contract with | ||||||
| 11 | Partnerships of
medical providers to arrange medical services | ||||||
| 12 | for persons eligible under
Section 5-2 of this Code. | ||||||
| 13 | Implementation of this Section may be by
demonstration | ||||||
| 14 | projects in certain geographic areas. The Partnership shall
be | ||||||
| 15 | represented by a sponsor organization. The Department, by | ||||||
| 16 | rule, shall
develop qualifications for sponsors of | ||||||
| 17 | Partnerships. Nothing in this
Section shall be construed to | ||||||
| 18 | require that the sponsor organization be a
medical | ||||||
| 19 | organization.
| ||||||
| 20 | The sponsor must negotiate formal written contracts with | ||||||
| 21 | medical
providers for physician services, inpatient and | ||||||
| 22 | outpatient hospital care,
home health services, treatment for | ||||||
| 23 | alcoholism and substance abuse, and
other services determined | ||||||
| 24 | necessary by the Illinois Department by rule for
delivery by | ||||||
| 25 | Partnerships. Physician services must include prenatal and
| ||||||
| 26 | obstetrical care. The Illinois Department shall reimburse | ||||||
| |||||||
| |||||||
| 1 | medical services
delivered by Partnership providers to clients | ||||||
| 2 | in target areas according to
provisions of this Article and | ||||||
| 3 | the Illinois Health Finance Reform Act,
except that:
| ||||||
| 4 | (1) Physicians participating in a Partnership and | ||||||
| 5 | providing certain
services, which shall be determined by | ||||||
| 6 | the Illinois Department, to persons
in areas covered by | ||||||
| 7 | the Partnership may receive an additional surcharge
for | ||||||
| 8 | such services.
| ||||||
| 9 | (2) The Department may elect to consider and negotiate | ||||||
| 10 | financial
incentives to encourage the development of | ||||||
| 11 | Partnerships and the efficient
delivery of medical care.
| ||||||
| 12 | (3) Persons receiving medical services through | ||||||
| 13 | Partnerships may receive
medical and case management | ||||||
| 14 | services above the level usually offered
through the | ||||||
| 15 | medical assistance program.
| ||||||
| 16 | Medical providers shall be required to meet certain | ||||||
| 17 | qualifications to
participate in Partnerships to ensure the | ||||||
| 18 | delivery of high quality medical
services. These | ||||||
| 19 | qualifications shall be determined by rule of the Illinois
| ||||||
| 20 | Department and may be higher than qualifications for | ||||||
| 21 | participation in the
medical assistance program. Partnership | ||||||
| 22 | sponsors may prescribe reasonable
additional qualifications | ||||||
| 23 | for participation by medical providers, only with
the prior | ||||||
| 24 | written approval of the Illinois Department.
| ||||||
| 25 | Nothing in this Section shall limit the free choice of | ||||||
| 26 | practitioners,
hospitals, and other providers of medical | ||||||
| |||||||
| |||||||
| 1 | services by clients.
In order to ensure patient freedom of | ||||||
| 2 | choice, the Illinois Department shall
immediately promulgate | ||||||
| 3 | all rules and take all other necessary actions so that
| ||||||
| 4 | provided services may be accessed from therapeutically | ||||||
| 5 | certified optometrists
to the full extent of the Illinois | ||||||
| 6 | Optometric Practice Act of 1987 without
discriminating between | ||||||
| 7 | service providers.
| ||||||
| 8 | The Department shall apply for a waiver from the United | ||||||
| 9 | States Health
Care Financing Administration to allow for the | ||||||
| 10 | implementation of
Partnerships under this Section.
| ||||||
| 11 | The Illinois Department shall require health care | ||||||
| 12 | providers to maintain
records that document the medical care | ||||||
| 13 | and services provided to recipients
of Medical Assistance | ||||||
| 14 | under this Article. Such records must be retained for a period | ||||||
| 15 | of not less than 6 years from the date of service or as | ||||||
| 16 | provided by applicable State law, whichever period is longer, | ||||||
| 17 | except that if an audit is initiated within the required | ||||||
| 18 | retention period then the records must be retained until the | ||||||
| 19 | audit is completed and every exception is resolved. The | ||||||
| 20 | Illinois Department shall
require health care providers to | ||||||
| 21 | make available, when authorized by the
patient, in writing, | ||||||
| 22 | the medical records in a timely fashion to other
health care | ||||||
| 23 | providers who are treating or serving persons eligible for
| ||||||
| 24 | Medical Assistance under this Article. All dispensers of | ||||||
| 25 | medical services
shall be required to maintain and retain | ||||||
| 26 | business and professional records
sufficient to fully and | ||||||
| |||||||
| |||||||
| 1 | accurately document the nature, scope, details and
receipt of | ||||||
| 2 | the health care provided to persons eligible for medical
| ||||||
| 3 | assistance under this Code, in accordance with regulations | ||||||
| 4 | promulgated by
the Illinois Department. The rules and | ||||||
| 5 | regulations shall require that proof
of the receipt of | ||||||
| 6 | prescription drugs, dentures, prosthetic devices and
| ||||||
| 7 | eyeglasses by eligible persons under this Section accompany | ||||||
| 8 | each claim
for reimbursement submitted by the dispenser of | ||||||
| 9 | such medical services.
No such claims for reimbursement shall | ||||||
| 10 | be approved for payment by the Illinois
Department without | ||||||
| 11 | such proof of receipt, unless the Illinois Department
shall | ||||||
| 12 | have put into effect and shall be operating a system of | ||||||
| 13 | post-payment
audit and review which shall, on a sampling | ||||||
| 14 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
| 15 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
| 16 | for which payment is being made are actually being
received by | ||||||
| 17 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
| 18 | (the effective date of Public Act 83-1439), the Illinois | ||||||
| 19 | Department shall establish a
current list of acquisition costs | ||||||
| 20 | for all prosthetic devices and any
other items recognized as | ||||||
| 21 | medical equipment and supplies reimbursable under
this Article | ||||||
| 22 | and shall update such list on a quarterly basis, except that
| ||||||
| 23 | the acquisition costs of all prescription drugs shall be | ||||||
| 24 | updated no
less frequently than every 30 days as required by | ||||||
| 25 | Section 5-5.12.
| ||||||
| 26 | Notwithstanding any other law to the contrary, the | ||||||
| |||||||
| |||||||
| 1 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
| 2 | (the effective date of Public Act 98-104), establish | ||||||
| 3 | procedures to permit skilled care facilities licensed under | ||||||
| 4 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
| 5 | reimbursement purposes. Following development of these | ||||||
| 6 | procedures, the Department shall, by July 1, 2016, test the | ||||||
| 7 | viability of the new system and implement any necessary | ||||||
| 8 | operational or structural changes to its information | ||||||
| 9 | technology platforms in order to allow for the direct | ||||||
| 10 | acceptance and payment of nursing home claims. | ||||||
| 11 | Notwithstanding any other law to the contrary, the | ||||||
| 12 | Illinois Department shall, within 365 days after August 15, | ||||||
| 13 | 2014 (the effective date of Public Act 98-963), establish | ||||||
| 14 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
| 15 | Community Care Act and MC/DD facilities licensed under the | ||||||
| 16 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
| 17 | purposes. Following development of these procedures, the | ||||||
| 18 | Department shall have an additional 365 days to test the | ||||||
| 19 | viability of the new system and to ensure that any necessary | ||||||
| 20 | operational or structural changes to its information | ||||||
| 21 | 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 | ||||||
| 12 | liens 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 | ||||||
| 15 | period of conditional enrollment, the Department may
terminate | ||||||
| 16 | the vendor's eligibility to participate in, or may disenroll | ||||||
| 17 | the 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 the category of risk | ||||||
| 24 | of 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 120 | ||||||
| 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 | ||||||
| 9 | to an accepted transaction shall be retained by a facility to | ||||||
| 10 | verify timely submittal. Once an admission transaction has | ||||||
| 11 | been completed, all resubmitted claims following prior | ||||||
| 12 | rejection are subject to receipt no later than 180 days after | ||||||
| 13 | the 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 | ||||||
| 22 | necessary to perform eligibility and payment verifications and | ||||||
| 23 | other 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 | ||||||
| 8 | into agreements with federal agencies and departments, under | ||||||
| 9 | which such agencies and departments shall share data necessary | ||||||
| 10 | for medical assistance program integrity functions and | ||||||
| 11 | oversight. The Illinois Department shall develop, in | ||||||
| 12 | cooperation with other State departments and agencies, and in | ||||||
| 13 | compliance with applicable federal laws and regulations, | ||||||
| 14 | appropriate and effective methods to share such data. At a | ||||||
| 15 | minimum, and to the extent necessary to provide data sharing, | ||||||
| 16 | the Illinois Department shall enter into agreements with State | ||||||
| 17 | agencies and departments, and is authorized to enter into | ||||||
| 18 | agreements with federal agencies and departments, including, | ||||||
| 19 | but not limited to: the Secretary of State; the Department of | ||||||
| 20 | Revenue; the Department of Public Health; the Department of | ||||||
| 21 | Human Services; and the Department of Financial and | ||||||
| 22 | Professional Regulation. | ||||||
| 23 | Beginning in fiscal year 2013, the Illinois Department | ||||||
| 24 | shall set forth a request for information to identify the | ||||||
| 25 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
| 26 | claims system with the goals of streamlining claims processing | ||||||
| |||||||
| |||||||
| 1 | and provider reimbursement, reducing the number of pending or | ||||||
| 2 | rejected claims, and helping to ensure a more transparent | ||||||
| 3 | adjudication process through the utilization of: (i) provider | ||||||
| 4 | data verification and provider screening technology; and (ii) | ||||||
| 5 | clinical code editing; and (iii) pre-pay, pre-adjudicated pre- | ||||||
| 6 | or post-adjudicated predictive modeling with an integrated | ||||||
| 7 | case management system with link analysis. Such a request for | ||||||
| 8 | information shall not be considered as a request for proposal | ||||||
| 9 | or as an obligation on the part of the Illinois Department to | ||||||
| 10 | take any action or acquire any products or services. | ||||||
| 11 | The Illinois Department shall establish policies, | ||||||
| 12 | procedures,
standards and criteria by rule for the | ||||||
| 13 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
| 14 | devices and durable medical equipment. Such
rules shall | ||||||
| 15 | provide, but not be limited to, the following services: (1)
| ||||||
| 16 | immediate repair or replacement of such devices by recipients; | ||||||
| 17 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
| 18 | medical equipment in a cost-effective manner, taking into
| ||||||
| 19 | consideration the recipient's medical prognosis, the extent of | ||||||
| 20 | the
recipient's needs, and the requirements and costs for | ||||||
| 21 | maintaining such
equipment. Subject to prior approval, such | ||||||
| 22 | rules shall enable a recipient to temporarily acquire and
use | ||||||
| 23 | alternative or substitute devices or equipment pending repairs | ||||||
| 24 | or
replacements of any device or equipment previously | ||||||
| 25 | authorized for such
recipient by the Department. | ||||||
| 26 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
| |||||||
| |||||||
| 1 | the Department may, by rule, exempt certain replacement | ||||||
| 2 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
| 3 | wheelchair parts, wheelchair accessories, and related seating | ||||||
| 4 | and positioning items, determine the wholesale price by | ||||||
| 5 | methods other than actual acquisition costs. | ||||||
| 6 | The Department shall require, by rule, all providers of | ||||||
| 7 | durable medical equipment to be accredited by an accreditation | ||||||
| 8 | organization approved by the federal Centers for Medicare and | ||||||
| 9 | Medicaid Services and recognized by the Department in order to | ||||||
| 10 | bill the Department for providing durable medical equipment to | ||||||
| 11 | recipients. No later than 15 months after the effective date | ||||||
| 12 | of the rule adopted pursuant to this paragraph, all providers | ||||||
| 13 | must meet the accreditation requirement.
| ||||||
| 14 | In order to promote environmental responsibility, meet the | ||||||
| 15 | needs of recipients and enrollees, and achieve significant | ||||||
| 16 | cost savings, the Department, or a managed care organization | ||||||
| 17 | under contract with the Department, may provide recipients or | ||||||
| 18 | managed care enrollees who have a prescription or Certificate | ||||||
| 19 | of Medical Necessity access to refurbished durable medical | ||||||
| 20 | equipment under this Section (excluding prosthetic and | ||||||
| 21 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
| 22 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
| 23 | products and associated services) through the State's | ||||||
| 24 | assistive technology program's reutilization program, using | ||||||
| 25 | staff with the Assistive Technology Professional (ATP) | ||||||
| 26 | Certification if the refurbished durable medical equipment: | ||||||
| |||||||
| |||||||
| 1 | (i) is available; (ii) is less expensive, including shipping | ||||||
| 2 | costs, than new durable medical equipment of the same type; | ||||||
| 3 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
| 4 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
| 5 | federal Food and Drug Administration regulations and guidance | ||||||
| 6 | governing the reprocessing of medical devices in health care | ||||||
| 7 | settings; and (v) equally meets the needs of the recipient or | ||||||
| 8 | enrollee. The reutilization program shall confirm that the | ||||||
| 9 | recipient or enrollee is not already in receipt of the same or | ||||||
| 10 | similar equipment from another service provider, and that the | ||||||
| 11 | refurbished durable medical equipment equally meets the needs | ||||||
| 12 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
| 13 | be construed to limit recipient or enrollee choice to obtain | ||||||
| 14 | new durable medical equipment or place any additional prior | ||||||
| 15 | authorization conditions on enrollees of managed care | ||||||
| 16 | organizations. | ||||||
| 17 | The Department shall execute, relative to the nursing home | ||||||
| 18 | prescreening
project, written inter-agency agreements with the | ||||||
| 19 | Department of Human
Services and the Department on Aging, to | ||||||
| 20 | effect the following: (i) intake
procedures and common | ||||||
| 21 | eligibility criteria for those persons who are receiving
| ||||||
| 22 | non-institutional services; and (ii) the establishment and | ||||||
| 23 | development of
non-institutional services in areas of the | ||||||
| 24 | State where they are not currently
available or are | ||||||
| 25 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
| 26 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
| |||||||
| |||||||
| 1 | increase in the determination of need (DON) scores from 29 to | ||||||
| 2 | 37 for applicants for institutional and home and | ||||||
| 3 | community-based long term care; if and only if federal | ||||||
| 4 | approval is not granted, the Department may, in conjunction | ||||||
| 5 | with other affected agencies, implement utilization controls | ||||||
| 6 | or changes in benefit packages to effectuate a similar savings | ||||||
| 7 | amount for this population; and (iv) no later than July 1, | ||||||
| 8 | 2013, minimum level of care eligibility criteria for | ||||||
| 9 | institutional and home and community-based long term care; and | ||||||
| 10 | (v) no later than October 1, 2013, establish procedures to | ||||||
| 11 | permit long term care providers access to eligibility scores | ||||||
| 12 | for individuals with an admission date who are seeking or | ||||||
| 13 | receiving services from the long term care provider. In order | ||||||
| 14 | to select the minimum level of care eligibility criteria, the | ||||||
| 15 | Governor shall establish a workgroup that includes affected | ||||||
| 16 | agency representatives and stakeholders representing the | ||||||
| 17 | institutional and home and community-based long term care | ||||||
| 18 | interests. This Section shall not restrict the Department from | ||||||
| 19 | implementing lower level of care eligibility criteria for | ||||||
| 20 | community-based services in circumstances where federal | ||||||
| 21 | approval has been granted.
| ||||||
| 22 | The Illinois Department shall develop and operate, in | ||||||
| 23 | cooperation
with other State Departments and agencies and in | ||||||
| 24 | compliance with
applicable federal laws and regulations, | ||||||
| 25 | appropriate and effective
systems of health care evaluation | ||||||
| 26 | and programs for monitoring of
utilization of health care | ||||||
| |||||||
| |||||||
| 1 | services and facilities, as it affects
persons eligible for | ||||||
| 2 | medical assistance under this Code.
| ||||||
| 3 | The Illinois Department shall report annually to the | ||||||
| 4 | General Assembly,
no later than the second Friday in April of | ||||||
| 5 | 1979 and each year
thereafter, in regard to:
| ||||||
| 6 | (a) actual statistics and trends in utilization of | ||||||
| 7 | medical services by
public aid recipients;
| ||||||
| 8 | (b) actual statistics and trends in the provision of | ||||||
| 9 | the various medical
services by medical vendors;
| ||||||
| 10 | (c) current rate structures and proposed changes in | ||||||
| 11 | those rate structures
for the various medical vendors; and
| ||||||
| 12 | (d) efforts at utilization review and control by the | ||||||
| 13 | Illinois Department.
| ||||||
| 14 | The period covered by each report shall be the 3 years | ||||||
| 15 | ending on the June
30 prior to the report. The report shall | ||||||
| 16 | include suggested legislation
for consideration by the General | ||||||
| 17 | Assembly. The requirement for reporting to the General | ||||||
| 18 | Assembly shall be satisfied
by filing copies of the report as | ||||||
| 19 | required by Section 3.1 of the General Assembly Organization | ||||||
| 20 | Act, and filing such additional
copies
with the State | ||||||
| 21 | Government Report Distribution Center for the General
Assembly | ||||||
| 22 | as is required under paragraph (t) of Section 7 of the State
| ||||||
| 23 | Library Act.
| ||||||
| 24 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
| 25 | any, is conditioned on the rules being adopted in accordance | ||||||
| 26 | with all provisions of the Illinois Administrative Procedure | ||||||
| |||||||
| |||||||
| 1 | Act and all rules and procedures of the Joint Committee on | ||||||
| 2 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 3 | whatever reason, is unauthorized. | ||||||
| 4 | On and after July 1, 2012, the Department shall reduce any | ||||||
| 5 | rate of reimbursement for services or other payments or alter | ||||||
| 6 | any methodologies authorized by this Code to reduce any rate | ||||||
| 7 | of reimbursement for services or other payments in accordance | ||||||
| 8 | with Section 5-5e. | ||||||
| 9 | Because kidney transplantation can be an appropriate, | ||||||
| 10 | cost-effective
alternative to renal dialysis when medically | ||||||
| 11 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
| 12 | of this Code, beginning October 1, 2014, the Department shall | ||||||
| 13 | cover kidney transplantation for noncitizens with end-stage | ||||||
| 14 | renal disease who are not eligible for comprehensive medical | ||||||
| 15 | benefits, who meet the residency requirements of Section 5-3 | ||||||
| 16 | of this Code, and who would otherwise meet the financial | ||||||
| 17 | requirements of the appropriate class of eligible persons | ||||||
| 18 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
| 19 | kidney transplantation, such person must be receiving | ||||||
| 20 | emergency renal dialysis services covered by the Department. | ||||||
| 21 | Providers under this Section shall be prior approved and | ||||||
| 22 | certified by the Department to perform kidney transplantation | ||||||
| 23 | and the services under this Section shall be limited to | ||||||
| 24 | services associated with kidney transplantation. | ||||||
| 25 | Notwithstanding any other provision of this Code to the | ||||||
| 26 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
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| 1 | medication assisted treatment prescribed for the treatment of | ||||||
| 2 | alcohol dependence or treatment of opioid dependence shall be | ||||||
| 3 | covered under both fee for service and managed care medical | ||||||
| 4 | assistance programs for persons who are otherwise eligible for | ||||||
| 5 | medical assistance under this Article and shall not be subject | ||||||
| 6 | to any (1) utilization control, other than those established | ||||||
| 7 | under the American Society of Addiction Medicine patient | ||||||
| 8 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
| 9 | lifetime restriction limit
mandate. | ||||||
| 10 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
| 11 | for the treatment of an opioid overdose, including the | ||||||
| 12 | medication product, administration devices, and any pharmacy | ||||||
| 13 | fees or hospital fees related to the dispensing, distribution, | ||||||
| 14 | and administration of the opioid antagonist, shall be covered | ||||||
| 15 | under the medical assistance program for persons who are | ||||||
| 16 | otherwise eligible for medical assistance under this Article. | ||||||
| 17 | As used in this Section, "opioid antagonist" means a drug that | ||||||
| 18 | binds to opioid receptors and blocks or inhibits the effect of | ||||||
| 19 | opioids acting on those receptors, including, but not limited | ||||||
| 20 | to, naloxone hydrochloride or any other similarly acting drug | ||||||
| 21 | approved by the U.S. Food and Drug Administration. The | ||||||
| 22 | Department shall not impose a copayment on the coverage | ||||||
| 23 | provided for naloxone hydrochloride under the medical | ||||||
| 24 | assistance program. | ||||||
| 25 | Upon federal approval, the Department shall provide | ||||||
| 26 | coverage and reimbursement for all drugs that are approved for | ||||||
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| 1 | marketing by the federal Food and Drug Administration and that | ||||||
| 2 | are recommended by the federal Public Health Service or the | ||||||
| 3 | United States Centers for Disease Control and Prevention for | ||||||
| 4 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
| 5 | services, including, but not limited to, HIV and sexually | ||||||
| 6 | transmitted infection screening, treatment for sexually | ||||||
| 7 | transmitted infections, medical monitoring, assorted labs, and | ||||||
| 8 | counseling to reduce the likelihood of HIV infection among | ||||||
| 9 | individuals who are not infected with HIV but who are at high | ||||||
| 10 | risk of HIV infection. | ||||||
| 11 | A federally qualified health center, as defined in Section | ||||||
| 12 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
| 13 | reimbursed by the Department in accordance with the federally | ||||||
| 14 | qualified health center's encounter rate for services provided | ||||||
| 15 | to medical assistance recipients that are performed by a | ||||||
| 16 | dental hygienist, as defined under the Illinois Dental | ||||||
| 17 | Practice Act, working under the general supervision of a | ||||||
| 18 | dentist and employed by a federally qualified health center. | ||||||
| 19 | Within 90 days after October 8, 2021 (the effective date | ||||||
| 20 | of Public Act 102-665), the Department shall seek federal | ||||||
| 21 | approval of a State Plan amendment to expand coverage for | ||||||
| 22 | family planning services that includes presumptive eligibility | ||||||
| 23 | to individuals whose income is at or below 208% of the federal | ||||||
| 24 | poverty level. Coverage under this Section shall be effective | ||||||
| 25 | beginning no later than December 1, 2022. | ||||||
| 26 | Subject to approval by the federal Centers for Medicare | ||||||
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| 1 | and Medicaid Services of a Title XIX State Plan amendment | ||||||
| 2 | electing the Program of All-Inclusive Care for the Elderly | ||||||
| 3 | (PACE) as a State Medicaid option, as provided for by Subtitle | ||||||
| 4 | I (commencing with Section 4801) of Title IV of the Balanced | ||||||
| 5 | Budget Act of 1997 (Public Law 105-33) and Part 460 | ||||||
| 6 | (commencing with Section 460.2) of Subchapter E of Title 42 of | ||||||
| 7 | the Code of Federal Regulations, PACE program services shall | ||||||
| 8 | become a covered benefit of the medical assistance program, | ||||||
| 9 | subject to criteria established in accordance with all | ||||||
| 10 | applicable laws. | ||||||
| 11 | Notwithstanding any other provision of this Code, | ||||||
| 12 | community-based pediatric palliative care from a trained | ||||||
| 13 | interdisciplinary team shall be covered under the medical | ||||||
| 14 | assistance program as provided in Section 15 of the Pediatric | ||||||
| 15 | Palliative
Care Act. | ||||||
| 16 | Notwithstanding any other provision of this Code, within | ||||||
| 17 | 12 months after June 2, 2022 (the effective date of Public Act | ||||||
| 18 | 102-1037) this amendatory Act of the 102nd General Assembly | ||||||
| 19 | and subject to federal approval, acupuncture services | ||||||
| 20 | performed by an acupuncturist licensed under the Acupuncture | ||||||
| 21 | Practice Act who is acting within the scope of his or her | ||||||
| 22 | license shall be covered under the medical assistance program. | ||||||
| 23 | The Department shall apply for any federal waiver or State | ||||||
| 24 | Plan amendment, if required, to implement this paragraph. The | ||||||
| 25 | Department may adopt any rules, including standards and | ||||||
| 26 | criteria, necessary to implement this paragraph. | ||||||
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