Bill Text: IL SB0622 | 2017-2018 | 100th General Assembly | Introduced


Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision requiring the Department of Healthcare and Family Services to determine the quantity and quality of medical services provided under the State's Medical Assistance program, provides that such services may include dental and periodontal prevention and treatment services for residents of long term care facilities and adults diagnosed with a developmental disability or an acquired disability that is permanent and irreversible and that occurred prior to age 21. Provides that on or after July 1, 2017, the Department shall provide dental services, including periodontal prevention and treatment and prescription eyeglasses to veterans and their dependents. Effective immediately.

Spectrum: Slight Partisan Bill (Democrat 3-1)

Status: (Introduced) 2017-05-15 - Placed on Calendar Order of 3rd Reading May 16, 2017 [SB0622 Detail]

Download: Illinois-2017-SB0622-Introduced.html


100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB0622

Introduced 1/24/2017, by Sen. Omar Aquino

SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5 from Ch. 23, par. 5-5

Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision requiring the Department of Healthcare and Family Services to determine the quantity and quality of medical services provided under the State's Medical Assistance program, provides that such services may include dental and periodontal prevention and treatment services for residents of long term care facilities and adults diagnosed with a developmental disability or an acquired disability that is permanent and irreversible and that occurred prior to age 21. Provides that on or after July 1, 2017, the Department shall provide dental services, including periodontal prevention and treatment and prescription eyeglasses to veterans and their dependents. Effective immediately.
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FISCAL NOTE ACT MAY APPLY

A BILL FOR

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1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5changing 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
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, residents of long term care facilities, and
22adults diagnosed with a developmental disability or an acquired
23disability that is permanent and irreversible and that occurred

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1prior to age 21, provided by an individual licensed to practice
2dentistry or dental surgery; for purposes of this item (10),
3"dental services" means diagnostic, preventive, or corrective
4procedures provided by or under the supervision of a dentist in
5the practice of his or her profession; (11) physical therapy
6and related services; (12) prescribed drugs, dentures, and
7prosthetic devices; and eyeglasses prescribed by a physician
8skilled in the diseases of the eye, or by an optometrist,
9whichever the person may select; (13) other diagnostic,
10screening, preventive, and rehabilitative services, including
11to ensure that the individual's need for intervention or
12treatment of mental disorders or substance use disorders or
13co-occurring mental health and substance use disorders is
14determined using a uniform screening, assessment, and
15evaluation process inclusive of criteria, for children and
16adults; for purposes of this item (13), a uniform screening,
17assessment, and evaluation process refers to a process that
18includes an appropriate evaluation and, as warranted, a
19referral; "uniform" does not mean the use of a singular
20instrument, tool, or process that all must utilize; (14)
21transportation and such other expenses as may be necessary;
22(15) medical treatment of sexual assault survivors, as defined
23in Section 1a of the Sexual Assault Survivors Emergency
24Treatment Act, for injuries sustained as a result of the sexual
25assault, including examinations and laboratory tests to
26discover evidence which may be used in criminal proceedings

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1arising from the sexual assault; (16) the diagnosis and
2treatment of sickle cell anemia; and (17) any other medical
3care, and any other type of remedial care recognized under the
4laws of this State, but not including abortions, or induced
5miscarriages or premature births, unless, in the opinion of a
6physician, such procedures are necessary for the preservation
7of the life of the woman seeking such treatment, or except an
8induced premature birth intended to produce a live viable child
9and such procedure is necessary for the health of the mother or
10her unborn child. The Illinois Department, by rule, shall
11prohibit any physician from providing medical assistance to
12anyone eligible therefor under this Code where such physician
13has been found guilty of performing an abortion procedure in a
14wilful and wanton manner upon a woman who was not pregnant at
15the time such abortion procedure was performed. The term "any
16other type of remedial care" shall include nursing care and
17nursing home service for persons who rely on treatment by
18spiritual means alone through prayer for healing.
19 Notwithstanding any other provision of this Section, a
20comprehensive tobacco use cessation program that includes
21purchasing prescription drugs or prescription medical devices
22approved by the Food and Drug Administration shall be covered
23under the medical assistance program under this Article for
24persons who are otherwise eligible for assistance under this
25Article.
26 Notwithstanding any other provision of this Code, the

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1Illinois Department may not require, as a condition of payment
2for any laboratory test authorized under this Article, that a
3physician's handwritten signature appear on the laboratory
4test order form. The Illinois Department may, however, impose
5other appropriate requirements regarding laboratory test order
6documentation.
7 Upon receipt of federal approval of an amendment to the
8Illinois Title XIX State Plan for this purpose, the Department
9shall authorize the Chicago Public Schools (CPS) to procure a
10vendor or vendors to manufacture eyeglasses for individuals
11enrolled in a school within the CPS system. CPS shall ensure
12that its vendor or vendors are enrolled as providers in the
13medical assistance program and in any capitated Medicaid
14managed care entity (MCE) serving individuals enrolled in a
15school within the CPS system. Under any contract procured under
16this provision, the vendor or vendors must serve only
17individuals enrolled in a school within the CPS system. Claims
18for services provided by CPS's vendor or vendors to recipients
19of benefits in the medical assistance program under this Code,
20the Children's Health Insurance Program, or the Covering ALL
21KIDS Health Insurance Program shall be submitted to the
22Department or the MCE in which the individual is enrolled for
23payment and shall be reimbursed at the Department's or the
24MCE's established rates or rate methodologies for eyeglasses.
25 On and after July 1, 2012, the Department of Healthcare and
26Family Services may provide the following services to persons

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1eligible for assistance under this Article who are
2participating in education, training or employment programs
3operated by the Department of Human Services as successor to
4the Department of Public Aid:
5 (1) dental services provided by or under the
6 supervision of a dentist; and
7 (2) eyeglasses prescribed by a physician skilled in the
8 diseases of the eye, or by an optometrist, whichever the
9 person may select.
10 On or after July 1, 2017, the Department of Healthcare and
11Family Services shall provide the following services to any
12veteran and his or her dependents who are eligible for
13assistance under this Article if the veteran has served in a
14branch of the United States military for greater than 180 days
15after initial training and has not been dishonorably discharged
16from service:
17 (1) Dental services, including prevention and
18 treatment of periodontal disease and dental caries
19 disease, provided by an individual licensed to practice
20 dentistry or dental surgery. As used in this paragraph (1),
21 "dental services" means diagnostic, preventative, or
22 corrective procedures provided by or under the supervision
23 of a dentist in the practice of his or her profession.
24 (2) Eyeglasses prescribed by a physician skilled in
25 diseases of the eye or by an optometrist, whomever the
26 person may select.

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1 Notwithstanding any other provision of this Code and
2subject to federal approval, the Department may adopt rules to
3allow a dentist who is volunteering his or her service at no
4cost to render dental services through an enrolled
5not-for-profit health clinic without the dentist personally
6enrolling as a participating provider in the medical assistance
7program. A not-for-profit health clinic shall include a public
8health clinic or Federally Qualified Health Center or other
9enrolled provider, as determined by the Department, through
10which dental services covered under this Section are performed.
11The Department shall establish a process for payment of claims
12for reimbursement for covered dental services rendered under
13this provision.
14 The Illinois Department, by rule, may distinguish and
15classify the medical services to be provided only in accordance
16with the classes of persons designated in Section 5-2.
17 The Department of Healthcare and Family Services must
18provide coverage and reimbursement for amino acid-based
19elemental formulas, regardless of delivery method, for the
20diagnosis and treatment of (i) eosinophilic disorders and (ii)
21short bowel syndrome when the prescribing physician has issued
22a written order stating that the amino acid-based elemental
23formula is medically necessary.
24 The Illinois Department shall authorize the provision of,
25and shall authorize payment for, screening by low-dose
26mammography for the presence of occult breast cancer for women

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135 years of age or older who are eligible for medical
2assistance under this Article, as follows:
3 (A) A baseline mammogram for women 35 to 39 years of
4 age.
5 (B) An annual mammogram for women 40 years of age or
6 older.
7 (C) A mammogram at the age and intervals considered
8 medically necessary by the woman's health care provider for
9 women under 40 years of age and having a family history of
10 breast cancer, prior personal history of breast cancer,
11 positive genetic testing, or other risk factors.
12 (D) A comprehensive ultrasound screening of an entire
13 breast or breasts if a mammogram demonstrates
14 heterogeneous or dense breast tissue, when medically
15 necessary as determined by a physician licensed to practice
16 medicine in all of its branches.
17 (E) A screening MRI when medically necessary, as
18 determined by a physician licensed to practice medicine in
19 all of its branches.
20 All screenings shall include a physical breast exam,
21instruction on self-examination and information regarding the
22frequency of self-examination and its value as a preventative
23tool. For purposes of this Section, "low-dose mammography"
24means the x-ray examination of the breast using equipment
25dedicated specifically for mammography, including the x-ray
26tube, filter, compression device, and image receptor, with an

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1average radiation exposure delivery of less than one rad per
2breast for 2 views of an average size breast. The term also
3includes digital mammography and includes breast
4tomosynthesis. As used in this Section, the term "breast
5tomosynthesis" means a radiologic procedure that involves the
6acquisition of projection images over the stationary breast to
7produce cross-sectional digital three-dimensional images of
8the breast. If, at any time, the Secretary of the United States
9Department of Health and Human Services, or its successor
10agency, promulgates rules or regulations to be published in the
11Federal Register or publishes a comment in the Federal Register
12or issues an opinion, guidance, or other action that would
13require the State, pursuant to any provision of the Patient
14Protection and Affordable Care Act (Public Law 111-148),
15including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
16successor provision, to defray the cost of any coverage for
17breast tomosynthesis outlined in this paragraph, then the
18requirement that an insurer cover breast tomosynthesis is
19inoperative other than any such coverage authorized under
20Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
21the State shall not assume any obligation for the cost of
22coverage for breast tomosynthesis set forth in this paragraph.
23 On and after January 1, 2016, the Department shall ensure
24that all networks of care for adult clients of the Department
25include access to at least one breast imaging Center of Imaging
26Excellence as certified by the American College of Radiology.

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1 On and after January 1, 2012, providers participating in a
2quality improvement program approved by the Department shall be
3reimbursed for screening and diagnostic mammography at the same
4rate as the Medicare program's rates, including the increased
5reimbursement for digital mammography.
6 The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10 On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16 The Department shall convene an expert panel, including
17representatives of hospitals, free standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22 Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the

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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3 The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7The Department shall work with experts in breast cancer
8outreach and patient navigation to optimize these reminders and
9shall establish a methodology for evaluating their
10effectiveness and modifying the methodology based on the
11evaluation.
12 The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18 The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. On or after July 1,
252016, the pilot program shall be expanded to include one site
26in western Illinois, one site in southern Illinois, one site in

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1central Illinois, and 4 sites within metropolitan Chicago. An
2evaluation of the pilot program shall be carried out measuring
3health outcomes and cost of care for those served by the pilot
4program compared to similarly situated patients who are not
5served by the pilot program.
6 The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include access
11for patients diagnosed with cancer to at least one academic
12commission on cancer-accredited cancer program as an
13in-network covered benefit.
14 Any medical or health care provider shall immediately
15recommend, to any pregnant woman who is being provided prenatal
16services and is suspected of drug abuse or is addicted as
17defined in the Alcoholism and Other Drug Abuse and Dependency
18Act, referral to a local substance abuse treatment provider
19licensed by the Department of Human Services or to a licensed
20hospital which provides substance abuse treatment services.
21The Department of Healthcare and Family Services shall assure
22coverage for the cost of treatment of the drug abuse or
23addiction for pregnant recipients in accordance with the
24Illinois Medicaid Program in conjunction with the Department of
25Human Services.
26 All medical providers providing medical assistance to

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1pregnant women under this Code shall receive information from
2the Department on the availability of services under the Drug
3Free Families with a Future or any comparable program providing
4case management services for addicted women, including
5information on appropriate referrals for other social services
6that may be needed by addicted women in addition to treatment
7for addiction.
8 The Illinois Department, in cooperation with the
9Departments of Human Services (as successor to the Department
10of Alcoholism and Substance Abuse) and Public Health, through a
11public awareness campaign, may provide information concerning
12treatment for alcoholism and drug abuse and addiction, prenatal
13health care, and other pertinent programs directed at reducing
14the number of drug-affected infants born to recipients of
15medical assistance.
16 Neither the Department of Healthcare and Family Services
17nor the Department of Human Services shall sanction the
18recipient solely on the basis of her substance abuse.
19 The Illinois Department shall establish such regulations
20governing the dispensing of health services under this Article
21as it shall deem appropriate. The Department should seek the
22advice of formal professional advisory committees appointed by
23the Director of the Illinois Department for the purpose of
24providing regular advice on policy and administrative matters,
25information dissemination and educational activities for
26medical and health care providers, and consistency in

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1procedures to the Illinois Department.
2 The Illinois Department may develop and contract with
3Partnerships of medical providers to arrange medical services
4for persons eligible under Section 5-2 of this Code.
5Implementation of this Section may be by demonstration projects
6in certain geographic areas. The Partnership shall be
7represented by a sponsor organization. The Department, by rule,
8shall develop qualifications for sponsors of Partnerships.
9Nothing in this Section shall be construed to require that the
10sponsor organization be a medical organization.
11 The sponsor must negotiate formal written contracts with
12medical providers for physician services, inpatient and
13outpatient hospital care, home health services, treatment for
14alcoholism and substance abuse, and other services determined
15necessary by the Illinois Department by rule for delivery by
16Partnerships. Physician services must include prenatal and
17obstetrical care. The Illinois Department shall reimburse
18medical services delivered by Partnership providers to clients
19in target areas according to provisions of this Article and the
20Illinois Health Finance Reform Act, except that:
21 (1) Physicians participating in a Partnership and
22 providing certain services, which shall be determined by
23 the Illinois Department, to persons in areas covered by the
24 Partnership may receive an additional surcharge for such
25 services.
26 (2) The Department may elect to consider and negotiate

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1 financial incentives to encourage the development of
2 Partnerships and the efficient delivery of medical care.
3 (3) Persons receiving medical services through
4 Partnerships may receive medical and case management
5 services above the level usually offered through the
6 medical assistance program.
7 Medical providers shall be required to meet certain
8qualifications to participate in Partnerships to ensure the
9delivery of high quality medical services. These
10qualifications shall be determined by rule of the Illinois
11Department and may be higher than qualifications for
12participation in the medical assistance program. Partnership
13sponsors may prescribe reasonable additional qualifications
14for participation by medical providers, only with the prior
15written approval of the Illinois Department.
16 Nothing in this Section shall limit the free choice of
17practitioners, hospitals, and other providers of medical
18services by clients. In order to ensure patient freedom of
19choice, the Illinois Department shall immediately promulgate
20all rules and take all other necessary actions so that provided
21services may be accessed from therapeutically certified
22optometrists to the full extent of the Illinois Optometric
23Practice Act of 1987 without discriminating between service
24providers.
25 The Department shall apply for a waiver from the United
26States Health Care Financing Administration to allow for the

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1implementation of Partnerships under this Section.
2 The Illinois Department shall require health care
3providers to maintain records that document the medical care
4and services provided to recipients of Medical Assistance under
5this Article. Such records must be retained for a period of not
6less than 6 years from the date of service or as provided by
7applicable State law, whichever period is longer, except that
8if an audit is initiated within the required retention period
9then the records must be retained until the audit is completed
10and every exception is resolved. The Illinois Department shall
11require health care providers to make available, when
12authorized by the patient, in writing, the medical records in a
13timely fashion to other health care providers who are treating
14or serving persons eligible for Medical Assistance under this
15Article. All dispensers of medical services shall be required
16to maintain and retain business and professional records
17sufficient to fully and accurately document the nature, scope,
18details and receipt of the health care provided to persons
19eligible for medical assistance under this Code, in accordance
20with regulations promulgated by the Illinois Department. The
21rules and regulations shall require that proof of the receipt
22of prescription drugs, dentures, prosthetic devices and
23eyeglasses by eligible persons under this Section accompany
24each claim for reimbursement submitted by the dispenser of such
25medical services. No such claims for reimbursement shall be
26approved for payment by the Illinois Department without such

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1proof of receipt, unless the Illinois Department shall have put
2into effect and shall be operating a system of post-payment
3audit and review which shall, on a sampling basis, be deemed
4adequate by the Illinois Department to assure that such drugs,
5dentures, prosthetic devices and eyeglasses for which payment
6is being made are actually being received by eligible
7recipients. Within 90 days after September 16, 1984 (the
8effective date of Public Act 83-1439), the Illinois Department
9shall establish a current list of acquisition costs for all
10prosthetic devices and any other items recognized as medical
11equipment and supplies reimbursable under this Article and
12shall update such list on a quarterly basis, except that the
13acquisition costs of all prescription drugs shall be updated no
14less frequently than every 30 days as required by Section
155-5.12.
16 The rules and regulations of the Illinois Department shall
17require that a written statement including the required opinion
18of a physician shall accompany any claim for reimbursement for
19abortions, or induced miscarriages or premature births. This
20statement shall indicate what procedures were used in providing
21such medical services.
22 Notwithstanding any other law to the contrary, the Illinois
23Department shall, within 365 days after July 22, 2013 (the
24effective date of Public Act 98-104), establish procedures to
25permit skilled care facilities licensed under the Nursing Home
26Care Act to submit monthly billing claims for reimbursement

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1purposes. Following development of these procedures, the
2Department shall, by July 1, 2016, test the viability of the
3new system and implement any necessary operational or
4structural changes to its information technology platforms in
5order to allow for the direct acceptance and payment of nursing
6home claims.
7 Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after August 15, 2014 (the
9effective date of Public Act 98-963), establish procedures to
10permit ID/DD facilities licensed under the ID/DD Community Care
11Act and MC/DD facilities licensed under the MC/DD Act to submit
12monthly billing claims for reimbursement purposes. Following
13development of these procedures, the Department shall have an
14additional 365 days to test the viability of the new system and
15to ensure that any necessary operational or structural changes
16to its information technology platforms are implemented.
17 The Illinois Department shall require all dispensers of
18medical services, other than an individual practitioner or
19group of practitioners, desiring to participate in the Medical
20Assistance program established under this Article to disclose
21all financial, beneficial, ownership, equity, surety or other
22interests in any and all firms, corporations, partnerships,
23associations, business enterprises, joint ventures, agencies,
24institutions or other legal entities providing any form of
25health care services in this State under this Article.
26 The Illinois Department may require that all dispensers of

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1medical services desiring to participate in the medical
2assistance program established under this Article disclose,
3under such terms and conditions as the Illinois Department may
4by rule establish, all inquiries from clients and attorneys
5regarding medical bills paid by the Illinois Department, which
6inquiries could indicate potential existence of claims or liens
7for the Illinois Department.
8 Enrollment of a vendor shall be subject to a provisional
9period and shall be conditional for one year. During the period
10of conditional enrollment, the Department may terminate the
11vendor's eligibility to participate in, or may disenroll the
12vendor from, the medical assistance program without cause.
13Unless otherwise specified, such termination of eligibility or
14disenrollment is not subject to the Department's hearing
15process. However, a disenrolled vendor may reapply without
16penalty.
17 The Department has the discretion to limit the conditional
18enrollment period for vendors based upon category of risk of
19the vendor.
20 Prior to enrollment and during the conditional enrollment
21period in the medical assistance program, all vendors shall be
22subject to enhanced oversight, screening, and review based on
23the risk of fraud, waste, and abuse that is posed by the
24category of risk of the vendor. The Illinois Department shall
25establish the procedures for oversight, screening, and review,
26which may include, but need not be limited to: criminal and

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1financial background checks; fingerprinting; license,
2certification, and authorization verifications; unscheduled or
3unannounced site visits; database checks; prepayment audit
4reviews; audits; payment caps; payment suspensions; and other
5screening as required by federal or State law.
6 The Department shall define or specify the following: (i)
7by provider notice, the "category of risk of the vendor" for
8each type of vendor, which shall take into account the level of
9screening applicable to a particular category of vendor under
10federal law and regulations; (ii) by rule or provider notice,
11the maximum length of the conditional enrollment period for
12each category of risk of the vendor; and (iii) by rule, the
13hearing rights, if any, afforded to a vendor in each category
14of risk of the vendor that is terminated or disenrolled during
15the conditional enrollment period.
16 To be eligible for payment consideration, a vendor's
17payment claim or bill, either as an initial claim or as a
18resubmitted claim following prior rejection, must be received
19by the Illinois Department, or its fiscal intermediary, no
20later than 180 days after the latest date on the claim on which
21medical goods or services were provided, with the following
22exceptions:
23 (1) In the case of a provider whose enrollment is in
24 process by the Illinois Department, the 180-day period
25 shall not begin until the date on the written notice from
26 the Illinois Department that the provider enrollment is

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1 complete.
2 (2) In the case of errors attributable to the Illinois
3 Department or any of its claims processing intermediaries
4 which result in an inability to receive, process, or
5 adjudicate a claim, the 180-day period shall not begin
6 until the provider has been notified of the error.
7 (3) In the case of a provider for whom the Illinois
8 Department initiates the monthly billing process.
9 (4) In the case of a provider operated by a unit of
10 local government with a population exceeding 3,000,000
11 when local government funds finance federal participation
12 for claims payments.
13 For claims for services rendered during a period for which
14a recipient received retroactive eligibility, claims must be
15filed within 180 days after the Department determines the
16applicant is eligible. For claims for which the Illinois
17Department is not the primary payer, claims must be submitted
18to the Illinois Department within 180 days after the final
19adjudication by the primary payer.
20 In the case of long term care facilities, within 5 days of
21receipt by the facility of required prescreening information,
22data for new admissions shall be entered into the Medical
23Electronic Data Interchange (MEDI) or the Recipient
24Eligibility Verification (REV) System or successor system, and
25within 15 days of receipt by the facility of required
26prescreening information, admission documents shall be

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1submitted through MEDI or REV or shall be submitted directly to
2the Department of Human Services using required admission
3forms. Effective September 1, 2014, admission documents,
4including all prescreening information, must be submitted
5through MEDI or REV. Confirmation numbers assigned to an
6accepted transaction shall be retained by a facility to verify
7timely submittal. Once an admission transaction has been
8completed, all resubmitted claims following prior rejection
9are subject to receipt no later than 180 days after the
10admission transaction has been completed.
11 Claims that are not submitted and received in compliance
12with the foregoing requirements shall not be eligible for
13payment under the medical assistance program, and the State
14shall have no liability for payment of those claims.
15 To the extent consistent with applicable information and
16privacy, security, and disclosure laws, State and federal
17agencies and departments shall provide the Illinois Department
18access to confidential and other information and data necessary
19to perform eligibility and payment verifications and other
20Illinois Department functions. This includes, but is not
21limited to: information pertaining to licensure;
22certification; earnings; immigration status; citizenship; wage
23reporting; unearned and earned income; pension income;
24employment; supplemental security income; social security
25numbers; National Provider Identifier (NPI) numbers; the
26National Practitioner Data Bank (NPDB); program and agency

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1exclusions; taxpayer identification numbers; tax delinquency;
2corporate information; and death records.
3 The Illinois Department shall enter into agreements with
4State agencies and departments, and is authorized to enter into
5agreements with federal agencies and departments, under which
6such agencies and departments shall share data necessary for
7medical assistance program integrity functions and oversight.
8The Illinois Department shall develop, in cooperation with
9other State departments and agencies, and in compliance with
10applicable federal laws and regulations, appropriate and
11effective methods to share such data. At a minimum, and to the
12extent necessary to provide data sharing, the Illinois
13Department shall enter into agreements with State agencies and
14departments, and is authorized to enter into agreements with
15federal agencies and departments, including but not limited to:
16the Secretary of State; the Department of Revenue; the
17Department of Public Health; the Department of Human Services;
18and the Department of Financial and Professional Regulation.
19 Beginning in fiscal year 2013, the Illinois Department
20shall set forth a request for information to identify the
21benefits of a pre-payment, post-adjudication, and post-edit
22claims system with the goals of streamlining claims processing
23and provider reimbursement, reducing the number of pending or
24rejected claims, and helping to ensure a more transparent
25adjudication process through the utilization of: (i) provider
26data verification and provider screening technology; and (ii)

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1clinical code editing; and (iii) pre-pay, pre- or
2post-adjudicated predictive modeling with an integrated case
3management system with link analysis. Such a request for
4information shall not be considered as a request for proposal
5or as an obligation on the part of the Illinois Department to
6take any action or acquire any products or services.
7 The Illinois Department shall establish policies,
8procedures, standards and criteria by rule for the acquisition,
9repair and replacement of orthotic and prosthetic devices and
10durable medical equipment. Such rules shall provide, but not be
11limited to, the following services: (1) immediate repair or
12replacement of such devices by recipients; and (2) rental,
13lease, purchase or lease-purchase of durable medical equipment
14in a cost-effective manner, taking into consideration the
15recipient's medical prognosis, the extent of the recipient's
16needs, and the requirements and costs for maintaining such
17equipment. Subject to prior approval, such rules shall enable a
18recipient to temporarily acquire and use alternative or
19substitute devices or equipment pending repairs or
20replacements of any device or equipment previously authorized
21for such recipient by the Department. Notwithstanding any
22provision of Section 5-5f to the contrary, the Department may,
23by rule, exempt certain replacement wheelchair parts from prior
24approval and, for wheelchairs, wheelchair parts, wheelchair
25accessories, and related seating and positioning items,
26determine the wholesale price by methods other than actual

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1acquisition costs.
2 The Department shall require, by rule, all providers of
3durable medical equipment to be accredited by an accreditation
4organization approved by the federal Centers for Medicare and
5Medicaid Services and recognized by the Department in order to
6bill the Department for providing durable medical equipment to
7recipients. No later than 15 months after the effective date of
8the rule adopted pursuant to this paragraph, all providers must
9meet the accreditation requirement.
10 The Department shall execute, relative to the nursing home
11prescreening project, written inter-agency agreements with the
12Department of Human Services and the Department on Aging, to
13effect the following: (i) intake procedures and common
14eligibility criteria for those persons who are receiving
15non-institutional services; and (ii) the establishment and
16development of non-institutional services in areas of the State
17where they are not currently available or are undeveloped; and
18(iii) notwithstanding any other provision of law, subject to
19federal approval, on and after July 1, 2012, an increase in the
20determination of need (DON) scores from 29 to 37 for applicants
21for institutional and home and community-based long term care;
22if and only if federal approval is not granted, the Department
23may, in conjunction with other affected agencies, implement
24utilization controls or changes in benefit packages to
25effectuate a similar savings amount for this population; and
26(iv) no later than July 1, 2013, minimum level of care

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1eligibility criteria for institutional and home and
2community-based long term care; and (v) no later than October
31, 2013, establish procedures to permit long term care
4providers access to eligibility scores for individuals with an
5admission date who are seeking or receiving services from the
6long term care provider. In order to select the minimum level
7of care eligibility criteria, the Governor shall establish a
8workgroup that includes affected agency representatives and
9stakeholders representing the institutional and home and
10community-based long term care interests. This Section shall
11not restrict the Department from implementing lower level of
12care eligibility criteria for community-based services in
13circumstances where federal approval has been granted.
14 The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation and
18programs for monitoring of utilization of health care services
19and facilities, as it affects persons eligible for medical
20assistance under this Code.
21 The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24 (a) actual statistics and trends in utilization of
25 medical services by public aid recipients;
26 (b) actual statistics and trends in the provision of

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1 the various medical services by medical vendors;
2 (c) current rate structures and proposed changes in
3 those rate structures for the various medical vendors; and
4 (d) efforts at utilization review and control by the
5 Illinois Department.
6 The period covered by each report shall be the 3 years
7ending on the June 30 prior to the report. The report shall
8include suggested legislation for consideration by the General
9Assembly. The filing of one copy of the report with the
10Speaker, one copy with the Minority Leader and one copy with
11the Clerk of the House of Representatives, one copy with the
12President, one copy with the Minority Leader and one copy with
13the Secretary of the Senate, one copy with the Legislative
14Research Unit, and such additional copies with the State
15Government Report Distribution Center for the General Assembly
16as is required under paragraph (t) of Section 7 of the State
17Library Act shall be deemed sufficient to comply with this
18Section.
19 Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25 On and after July 1, 2012, the Department shall reduce any
26rate of reimbursement for services or other payments or alter

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1any methodologies authorized by this Code to reduce any rate of
2reimbursement for services or other payments in accordance with
3Section 5-5e.
4 Because kidney transplantation can be an appropriate, cost
5effective alternative to renal dialysis when medically
6necessary and notwithstanding the provisions of Section 1-11 of
7this Code, beginning October 1, 2014, the Department shall
8cover kidney transplantation for noncitizens with end-stage
9renal disease who are not eligible for comprehensive medical
10benefits, who meet the residency requirements of Section 5-3 of
11this Code, and who would otherwise meet the financial
12requirements of the appropriate class of eligible persons under
13Section 5-2 of this Code. To qualify for coverage of kidney
14transplantation, such person must be receiving emergency renal
15dialysis services covered by the Department. Providers under
16this Section shall be prior approved and certified by the
17Department to perform kidney transplantation and the services
18under this Section shall be limited to services associated with
19kidney transplantation.
20 Notwithstanding any other provision of this Code to the
21contrary, on or after July 1, 2015, all FDA approved forms of
22medication assisted treatment prescribed for the treatment of
23alcohol dependence or treatment of opioid dependence shall be
24covered under both fee for service and managed care medical
25assistance programs for persons who are otherwise eligible for
26medical assistance under this Article and shall not be subject

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1to any (1) utilization control, other than those established
2under the American Society of Addiction Medicine patient
3placement criteria, (2) prior authorization mandate, or (3)
4lifetime restriction limit mandate.
5 On or after July 1, 2015, opioid antagonists prescribed for
6the treatment of an opioid overdose, including the medication
7product, administration devices, and any pharmacy fees related
8to the dispensing and administration of the opioid antagonist,
9shall be covered under the medical assistance program for
10persons who are otherwise eligible for medical assistance under
11this Article. As used in this Section, "opioid antagonist"
12means a drug that binds to opioid receptors and blocks or
13inhibits the effect of opioids acting on those receptors,
14including, but not limited to, naloxone hydrochloride or any
15other similarly acting drug approved by the U.S. Food and Drug
16Administration.
17 Upon federal approval, the Department shall provide
18coverage and reimbursement for all drugs that are approved for
19marketing by the federal Food and Drug Administration and that
20are recommended by the federal Public Health Service or the
21United States Centers for Disease Control and Prevention for
22pre-exposure prophylaxis and related pre-exposure prophylaxis
23services, including, but not limited to, HIV and sexually
24transmitted infection screening, treatment for sexually
25transmitted infections, medical monitoring, assorted labs, and
26counseling to reduce the likelihood of HIV infection among

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1individuals who are not infected with HIV but who are at high
2risk of HIV infection.
3(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
498-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
58-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
6eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
799-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
820 of P.A. 99-588 for the effective date of P.A. 99-407);
999-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
107-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
11eff. 1-1-17; revised 9-20-16.)
12 Section 99. Effective date. This Act takes effect upon
13becoming law.
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