Bill Text: IL SB0314 | 2017-2018 | 100th General Assembly | Engrossed


Bill Title: Amends the Consumer Installment Loan Act. Makes a technical change in a Section concerning a license required to engage in the business of making loans of money in a principal amount not exceeding $40,000.

Spectrum: Partisan Bill (Democrat 14-0)

Status: (Engrossed) 2017-05-25 - Placed on Calendar Order of 3rd Reading - Short Debate [SB0314 Detail]

Download: Illinois-2017-SB0314-Engrossed.html



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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
6 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
7 Sec. 356g. Mammograms; mastectomies.
8 (a) Every insurer shall provide in each group or individual
9policy, contract, or certificate of insurance issued or renewed
10for persons who are residents of this State, coverage for
11screening by low-dose mammography for all women 35 years of age
12or older for the presence of occult breast cancer within the
13provisions of the policy, contract, or certificate. The
14coverage shall be as follows:
15 (1) A baseline mammogram for women 35 to 39 years of
16 age.
17 (2) An annual mammogram for women 40 years of age or
18 older.
19 (3) A mammogram at the age and intervals considered
20 medically necessary by the woman's health care provider for
21 women under 40 years of age and having a family history of
22 breast cancer, prior personal history of breast cancer,
23 positive genetic testing, or other risk factors.

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1 (4) A comprehensive ultrasound screening and MRI of an
2 entire breast or breasts if a mammogram demonstrates
3 heterogeneous or dense breast tissue, when medically
4 necessary as determined by a physician licensed to practice
5 medicine in all of its branches.
6 (5) A screening MRI when medically necessary, as
7 determined by a physician licensed to practice medicine in
8 all of its branches.
9 For purposes of this Section, "low-dose mammography" means
10the x-ray examination of the breast using equipment dedicated
11specifically for mammography, including the x-ray tube,
12filter, compression device, and image receptor, with radiation
13exposure delivery of less than 1 rad per breast for 2 views of
14an average size breast. The term also includes digital
15mammography and includes breast tomosynthesis. As used in this
16Section, the term "breast tomosynthesis" means a radiologic
17procedure that involves the acquisition of projection images
18over the stationary breast to produce cross-sectional digital
19three-dimensional images of the breast.
20 If, at any time, the Secretary of the United States
21Department of Health and Human Services, or its successor
22agency, promulgates rules or regulations to be published in the
23Federal Register or publishes a comment in the Federal Register
24or issues an opinion, guidance, or other action that would
25require the State, pursuant to any provision of the Patient
26Protection and Affordable Care Act (Public Law 111-148),

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1including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
2successor provision, to defray the cost of any coverage for
3breast tomosynthesis outlined in this subsection, then the
4requirement that an insurer cover breast tomosynthesis is
5inoperative other than any such coverage authorized under
6Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
7the State shall not assume any obligation for the cost of
8coverage for breast tomosynthesis set forth in this subsection.
9 (a-5) Coverage as described by subsection (a) shall be
10provided at no cost to the insured and shall not be applied to
11an annual or lifetime maximum benefit.
12 (a-10) When health care services are available through
13contracted providers and a person does not comply with plan
14provisions specific to the use of contracted providers, the
15requirements of subsection (a-5) are not applicable. When a
16person does not comply with plan provisions specific to the use
17of contracted providers, plan provisions specific to the use of
18non-contracted providers must be applied without distinction
19for coverage required by this Section and shall be at least as
20favorable as for other radiological examinations covered by the
21policy or contract.
22 (b) No policy of accident or health insurance that provides
23for the surgical procedure known as a mastectomy shall be
24issued, amended, delivered, or renewed in this State unless
25that coverage also provides for prosthetic devices or
26reconstructive surgery incident to the mastectomy. Coverage

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1for breast reconstruction in connection with a mastectomy shall
2include:
3 (1) reconstruction of the breast upon which the
4 mastectomy has been performed;
5 (2) surgery and reconstruction of the other breast to
6 produce a symmetrical appearance; and
7 (3) prostheses and treatment for physical
8 complications at all stages of mastectomy, including
9 lymphedemas.
10Care shall be determined in consultation with the attending
11physician and the patient. The offered coverage for prosthetic
12devices and reconstructive surgery shall be subject to the
13deductible and coinsurance conditions applied to the
14mastectomy, and all other terms and conditions applicable to
15other benefits. When a mastectomy is performed and there is no
16evidence of malignancy then the offered coverage may be limited
17to the provision of prosthetic devices and reconstructive
18surgery to within 2 years after the date of the mastectomy. As
19used in this Section, "mastectomy" means the removal of all or
20part of the breast for medically necessary reasons, as
21determined by a licensed physician.
22 Written notice of the availability of coverage under this
23Section shall be delivered to the insured upon enrollment and
24annually thereafter. An insurer may not deny to an insured
25eligibility, or continued eligibility, to enroll or to renew
26coverage under the terms of the plan solely for the purpose of

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1avoiding the requirements of this Section. An insurer may not
2penalize or reduce or limit the reimbursement of an attending
3provider or provide incentives (monetary or otherwise) to an
4attending provider to induce the provider to provide care to an
5insured in a manner inconsistent with this Section.
6 (c) Rulemaking authority to implement Public Act 95-1045,
7if any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
13effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-588,
14eff. 7-20-16; 99-642, eff. 7-28-16.)
15 Section 10. The Health Maintenance Organization Act is
16amended by changing Section 4-6.1 as follows:
17 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
18 Sec. 4-6.1. Mammograms; mastectomies.
19 (a) Every contract or evidence of coverage issued by a
20Health Maintenance Organization for persons who are residents
21of this State shall contain coverage for screening by low-dose
22mammography for all women 35 years of age or older for the
23presence of occult breast cancer. The coverage shall be as
24follows:

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1 (1) A baseline mammogram for women 35 to 39 years of
2 age.
3 (2) An annual mammogram for women 40 years of age or
4 older.
5 (3) A mammogram at the age and intervals considered
6 medically necessary by the woman's health care provider for
7 women under 40 years of age and having a family history of
8 breast cancer, prior personal history of breast cancer,
9 positive genetic testing, or other risk factors.
10 (4) A comprehensive ultrasound screening and MRI of an
11 entire breast or breasts if a mammogram demonstrates
12 heterogeneous or dense breast tissue, when medically
13 necessary as determined by a physician licensed to practice
14 medicine in all of its branches.
15 For purposes of this Section, "low-dose mammography" means
16the x-ray examination of the breast using equipment dedicated
17specifically for mammography, including the x-ray tube,
18filter, compression device, and image receptor, with radiation
19exposure delivery of less than 1 rad per breast for 2 views of
20an average size breast. The term also includes digital
21mammography and includes breast tomosynthesis. As used in this
22Section, the term "breast tomosynthesis" means a radiologic
23procedure that involves the acquisition of projection images
24over the stationary breast to produce cross-sectional digital
25three-dimensional images of the breast.
26 If, at any time, the Secretary of the United States

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1Department of Health and Human Services, or its successor
2agency, promulgates rules or regulations to be published in the
3Federal Register or publishes a comment in the Federal Register
4or issues an opinion, guidance, or other action that would
5require the State, pursuant to any provision of the Patient
6Protection and Affordable Care Act (Public Law 111-148),
7including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
8successor provision, to defray the cost of any coverage for
9breast tomosynthesis outlined in this subsection, then the
10requirement that an insurer cover breast tomosynthesis is
11inoperative other than any such coverage authorized under
12Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
13the State shall not assume any obligation for the cost of
14coverage for breast tomosynthesis set forth in this subsection.
15 (a-5) Coverage as described in subsection (a) shall be
16provided at no cost to the enrollee and shall not be applied to
17an annual or lifetime maximum benefit.
18 (b) No contract or evidence of coverage issued by a health
19maintenance organization that provides for the surgical
20procedure known as a mastectomy shall be issued, amended,
21delivered, or renewed in this State on or after the effective
22date of this amendatory Act of the 92nd General Assembly unless
23that coverage also provides for prosthetic devices or
24reconstructive surgery incident to the mastectomy, providing
25that the mastectomy is performed after the effective date of
26this amendatory Act. Coverage for breast reconstruction in

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1connection with a mastectomy shall include:
2 (1) reconstruction of the breast upon which the
3 mastectomy has been performed;
4 (2) surgery and reconstruction of the other breast to
5 produce a symmetrical appearance; and
6 (3) prostheses and treatment for physical
7 complications at all stages of mastectomy, including
8 lymphedemas.
9Care shall be determined in consultation with the attending
10physician and the patient. The offered coverage for prosthetic
11devices and reconstructive surgery shall be subject to the
12deductible and coinsurance conditions applied to the
13mastectomy and all other terms and conditions applicable to
14other benefits. When a mastectomy is performed and there is no
15evidence of malignancy, then the offered coverage may be
16limited to the provision of prosthetic devices and
17reconstructive surgery to within 2 years after the date of the
18mastectomy. As used in this Section, "mastectomy" means the
19removal of all or part of the breast for medically necessary
20reasons, as determined by a licensed physician.
21 Written notice of the availability of coverage under this
22Section shall be delivered to the enrollee upon enrollment and
23annually thereafter. A health maintenance organization may not
24deny to an enrollee eligibility, or continued eligibility, to
25enroll or to renew coverage under the terms of the plan solely
26for the purpose of avoiding the requirements of this Section. A

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1health maintenance organization may not penalize or reduce or
2limit the reimbursement of an attending provider or provide
3incentives (monetary or otherwise) to an attending provider to
4induce the provider to provide care to an insured in a manner
5inconsistent with this Section.
6 (c) Rulemaking authority to implement this amendatory Act
7of the 95th General Assembly, if any, is conditioned on the
8rules being adopted in accordance with all provisions of the
9Illinois Administrative Procedure Act and all rules and
10procedures of the Joint Committee on Administrative Rules; any
11purported rule not so adopted, for whatever reason, is
12unauthorized.
13(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
14effective date of P.A. 99-407); 99-588, eff. 7-20-16.)
15 Section 15. The Illinois Public Aid Code is amended by
16changing Section 5-5 as follows:
17 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
18 Sec. 5-5. Medical services. The Illinois Department, by
19rule, shall determine the quantity and quality of and the rate
20of reimbursement for the medical assistance for which payment
21will be authorized, and the medical services to be provided,
22which may include all or part of the following: (1) inpatient
23hospital services; (2) outpatient hospital services; (3) other
24laboratory and X-ray services; (4) skilled nursing home

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1services; (5) physicians' services whether furnished in the
2office, the patient's home, a hospital, a skilled nursing home,
3or elsewhere; (6) medical care, or any other type of remedial
4care furnished by licensed practitioners; (7) home health care
5services; (8) private duty nursing service; (9) clinic
6services; (10) dental services, including prevention and
7treatment of periodontal disease and dental caries disease for
8pregnant women, provided by an individual licensed to practice
9dentistry or dental surgery; for purposes of this item (10),
10"dental services" means diagnostic, preventive, or corrective
11procedures provided by or under the supervision of a dentist in
12the practice of his or her profession; (11) physical therapy
13and related services; (12) prescribed drugs, dentures, and
14prosthetic devices; and eyeglasses prescribed by a physician
15skilled in the diseases of the eye, or by an optometrist,
16whichever the person may select; (13) other diagnostic,
17screening, preventive, and rehabilitative services, including
18to ensure that the individual's need for intervention or
19treatment of mental disorders or substance use disorders or
20co-occurring mental health and substance use disorders is
21determined using a uniform screening, assessment, and
22evaluation process inclusive of criteria, for children and
23adults; for purposes of this item (13), a uniform screening,
24assessment, and evaluation process refers to a process that
25includes an appropriate evaluation and, as warranted, a
26referral; "uniform" does not mean the use of a singular

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1instrument, tool, or process that all must utilize; (14)
2transportation and such other expenses as may be necessary;
3(15) medical treatment of sexual assault survivors, as defined
4in Section 1a of the Sexual Assault Survivors Emergency
5Treatment Act, for injuries sustained as a result of the sexual
6assault, including examinations and laboratory tests to
7discover evidence which may be used in criminal proceedings
8arising from the sexual assault; (16) the diagnosis and
9treatment of sickle cell anemia; and (17) any other medical
10care, and any other type of remedial care recognized under the
11laws of this State, but not including abortions, or induced
12miscarriages or premature births, unless, in the opinion of a
13physician, such procedures are necessary for the preservation
14of the life of the woman seeking such treatment, or except an
15induced premature birth intended to produce a live viable child
16and such procedure is necessary for the health of the mother or
17her unborn child. The Illinois Department, by rule, shall
18prohibit any physician from providing medical assistance to
19anyone eligible therefor under this Code where such physician
20has been found guilty of performing an abortion procedure in a
21wilful and wanton manner upon a woman who was not pregnant at
22the time such abortion procedure was performed. The term "any
23other type of remedial care" shall include nursing care and
24nursing home service for persons who rely on treatment by
25spiritual means alone through prayer for healing.
26 Notwithstanding any other provision of this Section, a

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1comprehensive tobacco use cessation program that includes
2purchasing prescription drugs or prescription medical devices
3approved by the Food and Drug Administration shall be covered
4under the medical assistance program under this Article for
5persons who are otherwise eligible for assistance under this
6Article.
7 Notwithstanding any other provision of this Code, the
8Illinois Department may not require, as a condition of payment
9for any laboratory test authorized under this Article, that a
10physician's handwritten signature appear on the laboratory
11test order form. The Illinois Department may, however, impose
12other appropriate requirements regarding laboratory test order
13documentation.
14 Upon receipt of federal approval of an amendment to the
15Illinois Title XIX State Plan for this purpose, the Department
16shall authorize the Chicago Public Schools (CPS) to procure a
17vendor or vendors to manufacture eyeglasses for individuals
18enrolled in a school within the CPS system. CPS shall ensure
19that its vendor or vendors are enrolled as providers in the
20medical assistance program and in any capitated Medicaid
21managed care entity (MCE) serving individuals enrolled in a
22school within the CPS system. Under any contract procured under
23this provision, the vendor or vendors must serve only
24individuals enrolled in a school within the CPS system. Claims
25for services provided by CPS's vendor or vendors to recipients
26of benefits in the medical assistance program under this Code,

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1the Children's Health Insurance Program, or the Covering ALL
2KIDS Health Insurance Program shall be submitted to the
3Department or the MCE in which the individual is enrolled for
4payment and shall be reimbursed at the Department's or the
5MCE's established rates or rate methodologies for eyeglasses.
6 On and after July 1, 2012, the Department of Healthcare and
7Family Services may provide the following services to persons
8eligible for assistance under this Article who are
9participating in education, training or employment programs
10operated by the Department of Human Services as successor to
11the Department of Public Aid:
12 (1) dental services provided by or under the
13 supervision of a dentist; and
14 (2) eyeglasses prescribed by a physician skilled in the
15 diseases of the eye, or by an optometrist, whichever the
16 person may select.
17 Notwithstanding any other provision of this Code and
18subject to federal approval, the Department may adopt rules to
19allow a dentist who is volunteering his or her service at no
20cost to render dental services through an enrolled
21not-for-profit health clinic without the dentist personally
22enrolling as a participating provider in the medical assistance
23program. A not-for-profit health clinic shall include a public
24health clinic or Federally Qualified Health Center or other
25enrolled provider, as determined by the Department, through
26which dental services covered under this Section are performed.

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1The Department shall establish a process for payment of claims
2for reimbursement for covered dental services rendered under
3this provision.
4 The Illinois Department, by rule, may distinguish and
5classify the medical services to be provided only in accordance
6with the classes of persons designated in Section 5-2.
7 The Department of Healthcare and Family Services must
8provide coverage and reimbursement for amino acid-based
9elemental formulas, regardless of delivery method, for the
10diagnosis and treatment of (i) eosinophilic disorders and (ii)
11short bowel syndrome when the prescribing physician has issued
12a written order stating that the amino acid-based elemental
13formula is medically necessary.
14 The Illinois Department shall authorize the provision of,
15and shall authorize payment for, screening by low-dose
16mammography for the presence of occult breast cancer for women
1735 years of age or older who are eligible for medical
18assistance under this Article, as follows:
19 (A) A baseline mammogram for women 35 to 39 years of
20 age.
21 (B) An annual mammogram for women 40 years of age or
22 older.
23 (C) A mammogram at the age and intervals considered
24 medically necessary by the woman's health care provider for
25 women under 40 years of age and having a family history of
26 breast cancer, prior personal history of breast cancer,

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1 positive genetic testing, or other risk factors.
2 (D) A comprehensive ultrasound screening and MRI of an
3 entire breast or breasts if a mammogram demonstrates
4 heterogeneous or dense breast tissue, when medically
5 necessary as determined by a physician licensed to practice
6 medicine in all of its branches.
7 (E) A screening MRI when medically necessary, as
8 determined by a physician licensed to practice medicine in
9 all of its branches.
10 All screenings shall include a physical breast exam,
11instruction on self-examination and information regarding the
12frequency of self-examination and its value as a preventative
13tool. For purposes of this Section, "low-dose mammography"
14means the x-ray examination of the breast using equipment
15dedicated specifically for mammography, including the x-ray
16tube, filter, compression device, and image receptor, with an
17average radiation exposure delivery of less than one rad per
18breast for 2 views of an average size breast. The term also
19includes digital mammography and includes breast
20tomosynthesis. As used in this Section, the term "breast
21tomosynthesis" means a radiologic procedure that involves the
22acquisition of projection images over the stationary breast to
23produce cross-sectional digital three-dimensional images of
24the breast. If, at any time, the Secretary of the United States
25Department of Health and Human Services, or its successor
26agency, promulgates rules or regulations to be published in the

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1Federal Register or publishes a comment in the Federal Register
2or issues an opinion, guidance, or other action that would
3require the State, pursuant to any provision of the Patient
4Protection and Affordable Care Act (Public Law 111-148),
5including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
6successor provision, to defray the cost of any coverage for
7breast tomosynthesis outlined in this paragraph, then the
8requirement that an insurer cover breast tomosynthesis is
9inoperative other than any such coverage authorized under
10Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
11the State shall not assume any obligation for the cost of
12coverage for breast tomosynthesis set forth in this paragraph.
13 On and after January 1, 2016, the Department shall ensure
14that all networks of care for adult clients of the Department
15include access to at least one breast imaging Center of Imaging
16Excellence as certified by the American College of Radiology.
17 On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall be
19reimbursed for screening and diagnostic mammography at the same
20rate as the Medicare program's rates, including the increased
21reimbursement for digital mammography.
22 The Department shall convene an expert panel including
23representatives of hospitals, free-standing mammography
24facilities, and doctors, including radiologists, to establish
25quality standards for mammography.
26 On and after January 1, 2017, providers participating in a

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1breast cancer treatment quality improvement program approved
2by the Department shall be reimbursed for breast cancer
3treatment at a rate that is no lower than 95% of the Medicare
4program's rates for the data elements included in the breast
5cancer treatment quality program.
6 The Department shall convene an expert panel, including
7representatives of hospitals, free standing breast cancer
8treatment centers, breast cancer quality organizations, and
9doctors, including breast surgeons, reconstructive breast
10surgeons, oncologists, and primary care providers to establish
11quality standards for breast cancer treatment.
12 Subject to federal approval, the Department shall
13establish a rate methodology for mammography at federally
14qualified health centers and other encounter-rate clinics.
15These clinics or centers may also collaborate with other
16hospital-based mammography facilities. By January 1, 2016, the
17Department shall report to the General Assembly on the status
18of the provision set forth in this paragraph.
19 The Department shall establish a methodology to remind
20women who are age-appropriate for screening mammography, but
21who have not received a mammogram within the previous 18
22months, of the importance and benefit of screening mammography.
23The Department shall work with experts in breast cancer
24outreach and patient navigation to optimize these reminders and
25shall establish a methodology for evaluating their
26effectiveness and modifying the methodology based on the

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1evaluation.
2 The Department shall establish a performance goal for
3primary care providers with respect to their female patients
4over age 40 receiving an annual mammogram. This performance
5goal shall be used to provide additional reimbursement in the
6form of a quality performance bonus to primary care providers
7who meet that goal.
8 The Department shall devise a means of case-managing or
9patient navigation for beneficiaries diagnosed with breast
10cancer. This program shall initially operate as a pilot program
11in areas of the State with the highest incidence of mortality
12related to breast cancer. At least one pilot program site shall
13be in the metropolitan Chicago area and at least one site shall
14be outside the metropolitan Chicago area. On or after July 1,
152016, the pilot program shall be expanded to include one site
16in western Illinois, one site in southern Illinois, one site in
17central Illinois, and 4 sites within metropolitan Chicago. An
18evaluation of the pilot program shall be carried out measuring
19health outcomes and cost of care for those served by the pilot
20program compared to similarly situated patients who are not
21served by the pilot program.
22 The Department shall require all networks of care to
23develop a means either internally or by contract with experts
24in navigation and community outreach to navigate cancer
25patients to comprehensive care in a timely fashion. The
26Department shall require all networks of care to include access

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1for patients diagnosed with cancer to at least one academic
2commission on cancer-accredited cancer program as an
3in-network covered benefit.
4 Any medical or health care provider shall immediately
5recommend, to any pregnant woman who is being provided prenatal
6services and is suspected of drug abuse or is addicted as
7defined in the Alcoholism and Other Drug Abuse and Dependency
8Act, referral to a local substance abuse treatment provider
9licensed by the Department of Human Services or to a licensed
10hospital which provides substance abuse treatment services.
11The Department of Healthcare and Family Services shall assure
12coverage for the cost of treatment of the drug abuse or
13addiction for pregnant recipients in accordance with the
14Illinois Medicaid Program in conjunction with the Department of
15Human Services.
16 All medical providers providing medical assistance to
17pregnant women under this Code shall receive information from
18the Department on the availability of services under the Drug
19Free Families with a Future or any comparable program providing
20case management services for addicted women, including
21information on appropriate referrals for other social services
22that may be needed by addicted women in addition to treatment
23for addiction.
24 The Illinois Department, in cooperation with the
25Departments of Human Services (as successor to the Department
26of Alcoholism and Substance Abuse) and Public Health, through a

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1public awareness campaign, may provide information concerning
2treatment for alcoholism and drug abuse and addiction, prenatal
3health care, and other pertinent programs directed at reducing
4the number of drug-affected infants born to recipients of
5medical assistance.
6 Neither the Department of Healthcare and Family Services
7nor the Department of Human Services shall sanction the
8recipient solely on the basis of her substance abuse.
9 The Illinois Department shall establish such regulations
10governing the dispensing of health services under this Article
11as it shall deem appropriate. The Department should seek the
12advice of formal professional advisory committees appointed by
13the Director of the Illinois Department for the purpose of
14providing regular advice on policy and administrative matters,
15information dissemination and educational activities for
16medical and health care providers, and consistency in
17procedures to the Illinois Department.
18 The Illinois Department may develop and contract with
19Partnerships of medical providers to arrange medical services
20for persons eligible under Section 5-2 of this Code.
21Implementation of this Section may be by demonstration projects
22in certain geographic areas. The Partnership shall be
23represented by a sponsor organization. The Department, by rule,
24shall develop qualifications for sponsors of Partnerships.
25Nothing in this Section shall be construed to require that the
26sponsor organization be a medical organization.

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1 The sponsor must negotiate formal written contracts with
2medical providers for physician services, inpatient and
3outpatient hospital care, home health services, treatment for
4alcoholism and substance abuse, and other services determined
5necessary by the Illinois Department by rule for delivery by
6Partnerships. Physician services must include prenatal and
7obstetrical care. The Illinois Department shall reimburse
8medical services delivered by Partnership providers to clients
9in target areas according to provisions of this Article and the
10Illinois Health Finance Reform Act, except that:
11 (1) Physicians participating in a Partnership and
12 providing certain services, which shall be determined by
13 the Illinois Department, to persons in areas covered by the
14 Partnership may receive an additional surcharge for such
15 services.
16 (2) The Department may elect to consider and negotiate
17 financial incentives to encourage the development of
18 Partnerships and the efficient delivery of medical care.
19 (3) Persons receiving medical services through
20 Partnerships may receive medical and case management
21 services above the level usually offered through the
22 medical assistance program.
23 Medical providers shall be required to meet certain
24qualifications to participate in Partnerships to ensure the
25delivery of high quality medical services. These
26qualifications shall be determined by rule of the Illinois

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1Department and may be higher than qualifications for
2participation in the medical assistance program. Partnership
3sponsors may prescribe reasonable additional qualifications
4for participation by medical providers, only with the prior
5written approval of the Illinois Department.
6 Nothing in this Section shall limit the free choice of
7practitioners, hospitals, and other providers of medical
8services by clients. In order to ensure patient freedom of
9choice, the Illinois Department shall immediately promulgate
10all rules and take all other necessary actions so that provided
11services may be accessed from therapeutically certified
12optometrists to the full extent of the Illinois Optometric
13Practice Act of 1987 without discriminating between service
14providers.
15 The Department shall apply for a waiver from the United
16States Health Care Financing Administration to allow for the
17implementation of Partnerships under this Section.
18 The Illinois Department shall require health care
19providers to maintain records that document the medical care
20and services provided to recipients of Medical Assistance under
21this Article. Such records must be retained for a period of not
22less than 6 years from the date of service or as provided by
23applicable State law, whichever period is longer, except that
24if an audit is initiated within the required retention period
25then the records must be retained until the audit is completed
26and every exception is resolved. The Illinois Department shall

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1require health care providers to make available, when
2authorized by the patient, in writing, the medical records in a
3timely fashion to other health care providers who are treating
4or serving persons eligible for Medical Assistance under this
5Article. All dispensers of medical services shall be required
6to maintain and retain business and professional records
7sufficient to fully and accurately document the nature, scope,
8details and receipt of the health care provided to persons
9eligible for medical assistance under this Code, in accordance
10with regulations promulgated by the Illinois Department. The
11rules and regulations shall require that proof of the receipt
12of prescription drugs, dentures, prosthetic devices and
13eyeglasses by eligible persons under this Section accompany
14each claim for reimbursement submitted by the dispenser of such
15medical services. No such claims for reimbursement shall be
16approved for payment by the Illinois Department without such
17proof of receipt, unless the Illinois Department shall have put
18into effect and shall be operating a system of post-payment
19audit and review which shall, on a sampling basis, be deemed
20adequate by the Illinois Department to assure that such drugs,
21dentures, prosthetic devices and eyeglasses for which payment
22is being made are actually being received by eligible
23recipients. Within 90 days after September 16, 1984 (the
24effective date of Public Act 83-1439), the Illinois Department
25shall establish a current list of acquisition costs for all
26prosthetic devices and any other items recognized as medical

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1equipment and supplies reimbursable under this Article and
2shall update such list on a quarterly basis, except that the
3acquisition costs of all prescription drugs shall be updated no
4less frequently than every 30 days as required by Section
55-5.12.
6 The rules and regulations of the Illinois Department shall
7require that a written statement including the required opinion
8of a physician shall accompany any claim for reimbursement for
9abortions, or induced miscarriages or premature births. This
10statement shall indicate what procedures were used in providing
11such medical services.
12 Notwithstanding any other law to the contrary, the Illinois
13Department shall, within 365 days after July 22, 2013 (the
14effective date of Public Act 98-104), establish procedures to
15permit skilled care facilities licensed under the Nursing Home
16Care Act to submit monthly billing claims for reimbursement
17purposes. Following development of these procedures, the
18Department shall, by July 1, 2016, test the viability of the
19new system and implement any necessary operational or
20structural changes to its information technology platforms in
21order to allow for the direct acceptance and payment of nursing
22home claims.
23 Notwithstanding any other law to the contrary, the Illinois
24Department shall, within 365 days after August 15, 2014 (the
25effective date of Public Act 98-963), establish procedures to
26permit ID/DD facilities licensed under the ID/DD Community Care

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1Act and MC/DD facilities licensed under the MC/DD Act to submit
2monthly billing claims for reimbursement purposes. Following
3development of these procedures, the Department shall have an
4additional 365 days to test the viability of the new system and
5to ensure that any necessary operational or structural changes
6to its information technology platforms are implemented.
7 The Illinois Department shall require all dispensers of
8medical services, other than an individual practitioner or
9group of practitioners, desiring to participate in the Medical
10Assistance program established under this Article to disclose
11all financial, beneficial, ownership, equity, surety or other
12interests in any and all firms, corporations, partnerships,
13associations, business enterprises, joint ventures, agencies,
14institutions or other legal entities providing any form of
15health care services in this State under this Article.
16 The Illinois Department may require that all dispensers of
17medical services desiring to participate in the medical
18assistance program established under this Article disclose,
19under such terms and conditions as the Illinois Department may
20by rule establish, all inquiries from clients and attorneys
21regarding medical bills paid by the Illinois Department, which
22inquiries could indicate potential existence of claims or liens
23for the Illinois Department.
24 Enrollment of a vendor shall be subject to a provisional
25period and shall be conditional for one year. During the period
26of conditional enrollment, the Department may terminate the

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1vendor's eligibility to participate in, or may disenroll the
2vendor from, the medical assistance program without cause.
3Unless otherwise specified, such termination of eligibility or
4disenrollment is not subject to the Department's hearing
5process. However, a disenrolled vendor may reapply without
6penalty.
7 The Department has the discretion to limit the conditional
8enrollment period for vendors based upon category of risk of
9the vendor.
10 Prior to enrollment and during the conditional enrollment
11period in the medical assistance program, all vendors shall be
12subject to enhanced oversight, screening, and review based on
13the risk of fraud, waste, and abuse that is posed by the
14category of risk of the vendor. The Illinois Department shall
15establish the procedures for oversight, screening, and review,
16which may include, but need not be limited to: criminal and
17financial background checks; fingerprinting; license,
18certification, and authorization verifications; unscheduled or
19unannounced site visits; database checks; prepayment audit
20reviews; audits; payment caps; payment suspensions; and other
21screening as required by federal or State law.
22 The Department shall define or specify the following: (i)
23by provider notice, the "category of risk of the vendor" for
24each type of vendor, which shall take into account the level of
25screening applicable to a particular category of vendor under
26federal law and regulations; (ii) by rule or provider notice,

SB0314 Engrossed- 27 -LRB100 05099 SMS 15109 b
1the maximum length of the conditional enrollment period for
2each category of risk of the vendor; and (iii) by rule, the
3hearing rights, if any, afforded to a vendor in each category
4of risk of the vendor that is terminated or disenrolled during
5the conditional enrollment period.
6 To be eligible for payment consideration, a vendor's
7payment claim or bill, either as an initial claim or as a
8resubmitted claim following prior rejection, must be received
9by the Illinois Department, or its fiscal intermediary, no
10later than 180 days after the latest date on the claim on which
11medical goods or services were provided, with the following
12exceptions:
13 (1) In the case of a provider whose enrollment is in
14 process by the Illinois Department, the 180-day period
15 shall not begin until the date on the written notice from
16 the Illinois Department that the provider enrollment is
17 complete.
18 (2) In the case of errors attributable to the Illinois
19 Department or any of its claims processing intermediaries
20 which result in an inability to receive, process, or
21 adjudicate a claim, the 180-day period shall not begin
22 until the provider has been notified of the error.
23 (3) In the case of a provider for whom the Illinois
24 Department initiates the monthly billing process.
25 (4) In the case of a provider operated by a unit of
26 local government with a population exceeding 3,000,000

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1 when local government funds finance federal participation
2 for claims payments.
3 For claims for services rendered during a period for which
4a recipient received retroactive eligibility, claims must be
5filed within 180 days after the Department determines the
6applicant is eligible. For claims for which the Illinois
7Department is not the primary payer, claims must be submitted
8to the Illinois Department within 180 days after the final
9adjudication by the primary payer.
10 In the case of long term care facilities, within 5 days of
11receipt by the facility of required prescreening information,
12data for new admissions shall be entered into the Medical
13Electronic Data Interchange (MEDI) or the Recipient
14Eligibility Verification (REV) System or successor system, and
15within 15 days of receipt by the facility of required
16prescreening information, admission documents shall be
17submitted through MEDI or REV or shall be submitted directly to
18the Department of Human Services using required admission
19forms. Effective September 1, 2014, admission documents,
20including all prescreening information, must be submitted
21through MEDI or REV. Confirmation numbers assigned to an
22accepted transaction shall be retained by a facility to verify
23timely submittal. Once an admission transaction has been
24completed, all resubmitted claims following prior rejection
25are subject to receipt no later than 180 days after the
26admission transaction has been completed.

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1 Claims that are not submitted and received in compliance
2with the foregoing requirements shall not be eligible for
3payment under the medical assistance program, and the State
4shall have no liability for payment of those claims.
5 To the extent consistent with applicable information and
6privacy, security, and disclosure laws, State and federal
7agencies and departments shall provide the Illinois Department
8access to confidential and other information and data necessary
9to perform eligibility and payment verifications and other
10Illinois Department functions. This includes, but is not
11limited to: information pertaining to licensure;
12certification; earnings; immigration status; citizenship; wage
13reporting; unearned and earned income; pension income;
14employment; supplemental security income; social security
15numbers; National Provider Identifier (NPI) numbers; the
16National Practitioner Data Bank (NPDB); program and agency
17exclusions; taxpayer identification numbers; tax delinquency;
18corporate information; and death records.
19 The Illinois Department shall enter into agreements with
20State agencies and departments, and is authorized to enter into
21agreements with federal agencies and departments, under which
22such agencies and departments shall share data necessary for
23medical assistance program integrity functions and oversight.
24The Illinois Department shall develop, in cooperation with
25other State departments and agencies, and in compliance with
26applicable federal laws and regulations, appropriate and

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1effective methods to share such data. At a minimum, and to the
2extent necessary to provide data sharing, the Illinois
3Department shall enter into agreements with State agencies and
4departments, and is authorized to enter into agreements with
5federal agencies and departments, including but not limited to:
6the Secretary of State; the Department of Revenue; the
7Department of Public Health; the Department of Human Services;
8and the Department of Financial and Professional Regulation.
9 Beginning in fiscal year 2013, the Illinois Department
10shall set forth a request for information to identify the
11benefits of a pre-payment, post-adjudication, and post-edit
12claims system with the goals of streamlining claims processing
13and provider reimbursement, reducing the number of pending or
14rejected claims, and helping to ensure a more transparent
15adjudication process through the utilization of: (i) provider
16data verification and provider screening technology; and (ii)
17clinical code editing; and (iii) pre-pay, pre- or
18post-adjudicated predictive modeling with an integrated case
19management system with link analysis. Such a request for
20information shall not be considered as a request for proposal
21or as an obligation on the part of the Illinois Department to
22take any action or acquire any products or services.
23 The Illinois Department shall establish policies,
24procedures, standards and criteria by rule for the acquisition,
25repair and replacement of orthotic and prosthetic devices and
26durable medical equipment. Such rules shall provide, but not be

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1limited to, the following services: (1) immediate repair or
2replacement of such devices by recipients; and (2) rental,
3lease, purchase or lease-purchase of durable medical equipment
4in a cost-effective manner, taking into consideration the
5recipient's medical prognosis, the extent of the recipient's
6needs, and the requirements and costs for maintaining such
7equipment. Subject to prior approval, such rules shall enable a
8recipient to temporarily acquire and use alternative or
9substitute devices or equipment pending repairs or
10replacements of any device or equipment previously authorized
11for such recipient by the Department. Notwithstanding any
12provision of Section 5-5f to the contrary, the Department may,
13by rule, exempt certain replacement wheelchair parts from prior
14approval and, for wheelchairs, wheelchair parts, wheelchair
15accessories, and related seating and positioning items,
16determine the wholesale price by methods other than actual
17acquisition costs.
18 The Department shall require, by rule, all providers of
19durable medical equipment to be accredited by an accreditation
20organization approved by the federal Centers for Medicare and
21Medicaid Services and recognized by the Department in order to
22bill the Department for providing durable medical equipment to
23recipients. No later than 15 months after the effective date of
24the rule adopted pursuant to this paragraph, all providers must
25meet the accreditation requirement.
26 The Department shall execute, relative to the nursing home

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1prescreening project, written inter-agency agreements with the
2Department of Human Services and the Department on Aging, to
3effect the following: (i) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (ii) the establishment and
6development of non-institutional services in areas of the State
7where they are not currently available or are undeveloped; and
8(iii) notwithstanding any other provision of law, subject to
9federal approval, on and after July 1, 2012, an increase in the
10determination of need (DON) scores from 29 to 37 for applicants
11for institutional and home and community-based long term care;
12if and only if federal approval is not granted, the Department
13may, in conjunction with other affected agencies, implement
14utilization controls or changes in benefit packages to
15effectuate a similar savings amount for this population; and
16(iv) no later than July 1, 2013, minimum level of care
17eligibility criteria for institutional and home and
18community-based long term care; and (v) no later than October
191, 2013, establish procedures to permit long term care
20providers access to eligibility scores for individuals with an
21admission date who are seeking or receiving services from the
22long term care provider. In order to select the minimum level
23of care eligibility criteria, the Governor shall establish a
24workgroup that includes affected agency representatives and
25stakeholders representing the institutional and home and
26community-based long term care interests. This Section shall

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1not restrict the Department from implementing lower level of
2care eligibility criteria for community-based services in
3circumstances where federal approval has been granted.
4 The Illinois Department shall develop and operate, in
5cooperation with other State Departments and agencies and in
6compliance with applicable federal laws and regulations,
7appropriate and effective systems of health care evaluation and
8programs for monitoring of utilization of health care services
9and facilities, as it affects persons eligible for medical
10assistance under this Code.
11 The Illinois Department shall report annually to the
12General Assembly, no later than the second Friday in April of
131979 and each year thereafter, in regard to:
14 (a) actual statistics and trends in utilization of
15 medical services by public aid recipients;
16 (b) actual statistics and trends in the provision of
17 the various medical services by medical vendors;
18 (c) current rate structures and proposed changes in
19 those rate structures for the various medical vendors; and
20 (d) efforts at utilization review and control by the
21 Illinois Department.
22 The period covered by each report shall be the 3 years
23ending on the June 30 prior to the report. The report shall
24include suggested legislation for consideration by the General
25Assembly. The filing of one copy of the report with the
26Speaker, one copy with the Minority Leader and one copy with

SB0314 Engrossed- 34 -LRB100 05099 SMS 15109 b
1the Clerk of the House of Representatives, one copy with the
2President, one copy with the Minority Leader and one copy with
3the Secretary of the Senate, one copy with the Legislative
4Research Unit, and such additional copies with the State
5Government Report Distribution Center for the General Assembly
6as is required under paragraph (t) of Section 7 of the State
7Library Act shall be deemed sufficient to comply with this
8Section.
9 Rulemaking authority to implement Public Act 95-1045, if
10any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15 On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate of
18reimbursement for services or other payments in accordance with
19Section 5-5e.
20 Because kidney transplantation can be an appropriate, cost
21effective alternative to renal dialysis when medically
22necessary and notwithstanding the provisions of Section 1-11 of
23this Code, beginning October 1, 2014, the Department shall
24cover kidney transplantation for noncitizens with end-stage
25renal disease who are not eligible for comprehensive medical
26benefits, who meet the residency requirements of Section 5-3 of

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1this Code, and who would otherwise meet the financial
2requirements of the appropriate class of eligible persons under
3Section 5-2 of this Code. To qualify for coverage of kidney
4transplantation, such person must be receiving emergency renal
5dialysis services covered by the Department. Providers under
6this Section shall be prior approved and certified by the
7Department to perform kidney transplantation and the services
8under this Section shall be limited to services associated with
9kidney transplantation.
10 Notwithstanding any other provision of this Code to the
11contrary, on or after July 1, 2015, all FDA approved forms of
12medication assisted treatment prescribed for the treatment of
13alcohol dependence or treatment of opioid dependence shall be
14covered under both fee for service and managed care medical
15assistance programs for persons who are otherwise eligible for
16medical assistance under this Article and shall not be subject
17to any (1) utilization control, other than those established
18under the American Society of Addiction Medicine patient
19placement criteria, (2) prior authorization mandate, or (3)
20lifetime restriction limit mandate.
21 On or after July 1, 2015, opioid antagonists prescribed for
22the treatment of an opioid overdose, including the medication
23product, administration devices, and any pharmacy fees related
24to the dispensing and administration of the opioid antagonist,
25shall be covered under the medical assistance program for
26persons who are otherwise eligible for medical assistance under

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1this Article. As used in this Section, "opioid antagonist"
2means a drug that binds to opioid receptors and blocks or
3inhibits the effect of opioids acting on those receptors,
4including, but not limited to, naloxone hydrochloride or any
5other similarly acting drug approved by the U.S. Food and Drug
6Administration.
7 Upon federal approval, the Department shall provide
8coverage and reimbursement for all drugs that are approved for
9marketing by the federal Food and Drug Administration and that
10are recommended by the federal Public Health Service or the
11United States Centers for Disease Control and Prevention for
12pre-exposure prophylaxis and related pre-exposure prophylaxis
13services, including, but not limited to, HIV and sexually
14transmitted infection screening, treatment for sexually
15transmitted infections, medical monitoring, assorted labs, and
16counseling to reduce the likelihood of HIV infection among
17individuals who are not infected with HIV but who are at high
18risk of HIV infection.
19(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2098-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
218-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
22eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2399-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2420 of P.A. 99-588 for the effective date of P.A. 99-407);
2599-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
267-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,

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1eff. 1-1-17; revised 9-20-16.)
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