Bill Text: IL SB1596 | 2017-2018 | 100th General Assembly | Introduced

Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning medical assistance for the treatment of alcohol dependence or opioid dependence, provides that on or after July 1, 2017 such coverage may be subject to utilization controls or prior authorization mandates consistent with the most current edition of the American Society of Addiction Medicine's National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, as now or hereafter revised, or any successor publication (rather than on or after July 1, 2015 such coverage shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate). Provides that on or after July 1, 2017, opioid antagonists prescribed for the treatment of an opioid overdose may be subject to (A) utilization controls or (B) prior authorization mandates consistent with the most current edition of the American Society of Addiction Medicine's National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, as now or hereafter revised, or any successor publication.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2017-05-05 - Senate Committee Amendment No. 1 Rule 3-9(a) / Re-referred to Assignments [SB1596 Detail]

Download: Illinois-2017-SB1596-Introduced.html

State of Illinois
2017 and 2018

Introduced 2/9/2017, by Sen. Dale A. Righter

305 ILCS 5/5-5 from Ch. 23, par. 5-5

Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning medical assistance for the treatment of alcohol dependence or opioid dependence, provides that on or after July 1, 2017 such coverage may be subject to utilization controls or prior authorization mandates consistent with the most current edition of the American Society of Addiction Medicine's National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, as now or hereafter revised, or any successor publication (rather than on or after July 1, 2015 such coverage shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate). Provides that on or after July 1, 2017, opioid antagonists prescribed for the treatment of an opioid overdose may be subject to (A) utilization controls or (B) prior authorization mandates consistent with the most current edition of the American Society of Addiction Medicine's National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, as now or hereafter revised, or any successor publication.
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SB1596LRB100 09130 KTG 19284 b
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, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective

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

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

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1test order form. The Illinois Department may, however, impose
2other appropriate requirements regarding laboratory test order
4 Upon receipt of federal approval of an amendment to the
5Illinois Title XIX State Plan for this purpose, the Department
6shall authorize the Chicago Public Schools (CPS) to procure a
7vendor or vendors to manufacture eyeglasses for individuals
8enrolled in a school within the CPS system. CPS shall ensure
9that its vendor or vendors are enrolled as providers in the
10medical assistance program and in any capitated Medicaid
11managed care entity (MCE) serving individuals enrolled in a
12school within the CPS system. Under any contract procured under
13this provision, the vendor or vendors must serve only
14individuals enrolled in a school within the CPS system. Claims
15for services provided by CPS's vendor or vendors to recipients
16of benefits in the medical assistance program under this Code,
17the Children's Health Insurance Program, or the Covering ALL
18KIDS Health Insurance Program shall be submitted to the
19Department or the MCE in which the individual is enrolled for
20payment and shall be reimbursed at the Department's or the
21MCE's established rates or rate methodologies for eyeglasses.
22 On and after July 1, 2012, the Department of Healthcare and
23Family Services may provide the following services to persons
24eligible for assistance under this Article who are
25participating in education, training or employment programs
26operated by the Department of Human Services as successor to

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1the Department of Public Aid:
2 (1) dental services provided by or under the
3 supervision of a dentist; and
4 (2) eyeglasses prescribed by a physician skilled in the
5 diseases of the eye, or by an optometrist, whichever the
6 person may select.
7 Notwithstanding any other provision of this Code and
8subject to federal approval, the Department may adopt rules to
9allow a dentist who is volunteering his or her service at no
10cost to render dental services through an enrolled
11not-for-profit health clinic without the dentist personally
12enrolling as a participating provider in the medical assistance
13program. A not-for-profit health clinic shall include a public
14health clinic or Federally Qualified Health Center or other
15enrolled provider, as determined by the Department, through
16which dental services covered under this Section are performed.
17The Department shall establish a process for payment of claims
18for reimbursement for covered dental services rendered under
19this provision.
20 The Illinois Department, by rule, may distinguish and
21classify the medical services to be provided only in accordance
22with the classes of persons designated in Section 5-2.
23 The Department of Healthcare and Family Services must
24provide coverage and reimbursement for amino acid-based
25elemental formulas, regardless of delivery method, for the
26diagnosis and treatment of (i) eosinophilic disorders and (ii)

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1short bowel syndrome when the prescribing physician has issued
2a written order stating that the amino acid-based elemental
3formula is medically necessary.
4 The Illinois Department shall authorize the provision of,
5and shall authorize payment for, screening by low-dose
6mammography for the presence of occult breast cancer for women
735 years of age or older who are eligible for medical
8assistance under this Article, as follows:
9 (A) A baseline mammogram for women 35 to 39 years of
10 age.
11 (B) An annual mammogram for women 40 years of age or
12 older.
13 (C) A mammogram at the age and intervals considered
14 medically necessary by the woman's health care provider for
15 women under 40 years of age and having a family history of
16 breast cancer, prior personal history of breast cancer,
17 positive genetic testing, or other risk factors.
18 (D) A comprehensive ultrasound screening of an entire
19 breast or breasts if a mammogram demonstrates
20 heterogeneous or dense breast tissue, when medically
21 necessary as determined by a physician licensed to practice
22 medicine in all of its branches.
23 (E) A screening MRI when medically necessary, as
24 determined by a physician licensed to practice medicine in
25 all of its branches.
26 All screenings shall include a physical breast exam,

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1instruction on self-examination and information regarding the
2frequency of self-examination and its value as a preventative
3tool. For purposes of this Section, "low-dose mammography"
4means the x-ray examination of the breast using equipment
5dedicated specifically for mammography, including the x-ray
6tube, filter, compression device, and image receptor, with an
7average radiation exposure delivery of less than one rad per
8breast for 2 views of an average size breast. The term also
9includes digital mammography and includes breast
10tomosynthesis. As used in this Section, the term "breast
11tomosynthesis" means a radiologic procedure that involves the
12acquisition of projection images over the stationary breast to
13produce cross-sectional digital three-dimensional images of
14the breast. If, at any time, the Secretary of the United States
15Department of Health and Human Services, or its successor
16agency, promulgates rules or regulations to be published in the
17Federal Register or publishes a comment in the Federal Register
18or issues an opinion, guidance, or other action that would
19require the State, pursuant to any provision of the Patient
20Protection and Affordable Care Act (Public Law 111-148),
21including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
22successor provision, to defray the cost of any coverage for
23breast tomosynthesis outlined in this paragraph, then the
24requirement that an insurer cover breast tomosynthesis is
25inoperative other than any such coverage authorized under
26Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and

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1the State shall not assume any obligation for the cost of
2coverage for breast tomosynthesis set forth in this paragraph.
3 On and after January 1, 2016, the Department shall ensure
4that all networks of care for adult clients of the Department
5include access to at least one breast imaging Center of Imaging
6Excellence as certified by the American College of Radiology.
7 On and after January 1, 2012, providers participating in a
8quality improvement program approved by the Department shall be
9reimbursed for screening and diagnostic mammography at the same
10rate as the Medicare program's rates, including the increased
11reimbursement for digital mammography.
12 The Department shall convene an expert panel including
13representatives of hospitals, free-standing mammography
14facilities, and doctors, including radiologists, to establish
15quality standards for mammography.
16 On and after January 1, 2017, providers participating in a
17breast cancer treatment quality improvement program approved
18by the Department shall be reimbursed for breast cancer
19treatment at a rate that is no lower than 95% of the Medicare
20program's rates for the data elements included in the breast
21cancer treatment quality program.
22 The Department shall convene an expert panel, including
23representatives of hospitals, free standing breast cancer
24treatment centers, breast cancer quality organizations, and
25doctors, including breast surgeons, reconstructive breast
26surgeons, oncologists, and primary care providers to establish

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1quality standards for breast cancer treatment.
2 Subject to federal approval, the Department shall
3establish a rate methodology for mammography at federally
4qualified health centers and other encounter-rate clinics.
5These clinics or centers may also collaborate with other
6hospital-based mammography facilities. By January 1, 2016, the
7Department shall report to the General Assembly on the status
8of the provision set forth in this paragraph.
9 The Department shall establish a methodology to remind
10women who are age-appropriate for screening mammography, but
11who have not received a mammogram within the previous 18
12months, of the importance and benefit of screening mammography.
13The Department shall work with experts in breast cancer
14outreach and patient navigation to optimize these reminders and
15shall establish a methodology for evaluating their
16effectiveness and modifying the methodology based on the
18 The Department shall establish a performance goal for
19primary care providers with respect to their female patients
20over age 40 receiving an annual mammogram. This performance
21goal shall be used to provide additional reimbursement in the
22form of a quality performance bonus to primary care providers
23who meet that goal.
24 The Department shall devise a means of case-managing or
25patient navigation for beneficiaries diagnosed with breast
26cancer. This program shall initially operate as a pilot program

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1in areas of the State with the highest incidence of mortality
2related to breast cancer. At least one pilot program site shall
3be in the metropolitan Chicago area and at least one site shall
4be outside the metropolitan Chicago area. On or after July 1,
52016, the pilot program shall be expanded to include one site
6in western Illinois, one site in southern Illinois, one site in
7central Illinois, and 4 sites within metropolitan Chicago. An
8evaluation of the pilot program shall be carried out measuring
9health outcomes and cost of care for those served by the pilot
10program compared to similarly situated patients who are not
11served by the pilot program.
12 The Department shall require all networks of care to
13develop a means either internally or by contract with experts
14in navigation and community outreach to navigate cancer
15patients to comprehensive care in a timely fashion. The
16Department shall require all networks of care to include access
17for patients diagnosed with cancer to at least one academic
18commission on cancer-accredited cancer program as an
19in-network covered benefit.
20 Any medical or health care provider shall immediately
21recommend, to any pregnant woman who is being provided prenatal
22services and is suspected of drug abuse or is addicted as
23defined in the Alcoholism and Other Drug Abuse and Dependency
24Act, referral to a local substance abuse treatment provider
25licensed by the Department of Human Services or to a licensed
26hospital which provides substance abuse treatment services.

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

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1as it shall deem appropriate. The Department should seek the
2advice of formal professional advisory committees appointed by
3the Director of the Illinois Department for the purpose of
4providing regular advice on policy and administrative matters,
5information dissemination and educational activities for
6medical and health care providers, and consistency in
7procedures to the Illinois Department.
8 The Illinois Department may develop and contract with
9Partnerships of medical providers to arrange medical services
10for persons eligible under Section 5-2 of this Code.
11Implementation of this Section may be by demonstration projects
12in certain geographic areas. The Partnership shall be
13represented by a sponsor organization. The Department, by rule,
14shall develop qualifications for sponsors of Partnerships.
15Nothing in this Section shall be construed to require that the
16sponsor organization be a medical organization.
17 The sponsor must negotiate formal written contracts with
18medical providers for physician services, inpatient and
19outpatient hospital care, home health services, treatment for
20alcoholism and substance abuse, and other services determined
21necessary by the Illinois Department by rule for delivery by
22Partnerships. Physician services must include prenatal and
23obstetrical care. The Illinois Department shall reimburse
24medical services delivered by Partnership providers to clients
25in target areas according to provisions of this Article and the
26Illinois Health Finance Reform Act, except that:

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1 (1) Physicians participating in a Partnership and
2 providing certain services, which shall be determined by
3 the Illinois Department, to persons in areas covered by the
4 Partnership may receive an additional surcharge for such
5 services.
6 (2) The Department may elect to consider and negotiate
7 financial incentives to encourage the development of
8 Partnerships and the efficient delivery of medical care.
9 (3) Persons receiving medical services through
10 Partnerships may receive medical and case management
11 services above the level usually offered through the
12 medical assistance program.
13 Medical providers shall be required to meet certain
14qualifications to participate in Partnerships to ensure the
15delivery of high quality medical services. These
16qualifications shall be determined by rule of the Illinois
17Department and may be higher than qualifications for
18participation in the medical assistance program. Partnership
19sponsors may prescribe reasonable additional qualifications
20for participation by medical providers, only with the prior
21written approval of the Illinois Department.
22 Nothing in this Section shall limit the free choice of
23practitioners, hospitals, and other providers of medical
24services by clients. In order to ensure patient freedom of
25choice, the Illinois Department shall immediately promulgate
26all rules and take all other necessary actions so that provided

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1services may be accessed from therapeutically certified
2optometrists to the full extent of the Illinois Optometric
3Practice Act of 1987 without discriminating between service
5 The Department shall apply for a waiver from the United
6States Health Care Financing Administration to allow for the
7implementation of Partnerships under this Section.
8 The Illinois Department shall require health care
9providers to maintain records that document the medical care
10and services provided to recipients of Medical Assistance under
11this Article. Such records must be retained for a period of not
12less than 6 years from the date of service or as provided by
13applicable State law, whichever period is longer, except that
14if an audit is initiated within the required retention period
15then the records must be retained until the audit is completed
16and every exception is resolved. The Illinois Department shall
17require health care providers to make available, when
18authorized by the patient, in writing, the medical records in a
19timely fashion to other health care providers who are treating
20or serving persons eligible for Medical Assistance under this
21Article. All dispensers of medical services shall be required
22to maintain and retain business and professional records
23sufficient to fully and accurately document the nature, scope,
24details and receipt of the health care provided to persons
25eligible for medical assistance under this Code, in accordance
26with regulations promulgated by the Illinois Department. The

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1rules and regulations shall require that proof of the receipt
2of prescription drugs, dentures, prosthetic devices and
3eyeglasses by eligible persons under this Section accompany
4each claim for reimbursement submitted by the dispenser of such
5medical services. No such claims for reimbursement shall be
6approved for payment by the Illinois Department without such
7proof of receipt, unless the Illinois Department shall have put
8into effect and shall be operating a system of post-payment
9audit and review which shall, on a sampling basis, be deemed
10adequate by the Illinois Department to assure that such drugs,
11dentures, prosthetic devices and eyeglasses for which payment
12is being made are actually being received by eligible
13recipients. Within 90 days after September 16, 1984 (the
14effective date of Public Act 83-1439), the Illinois Department
15shall establish a current list of acquisition costs for all
16prosthetic devices and any other items recognized as medical
17equipment and supplies reimbursable under this Article and
18shall update such list on a quarterly basis, except that the
19acquisition costs of all prescription drugs shall be updated no
20less frequently than every 30 days as required by Section
22 The rules and regulations of the Illinois Department shall
23require that a written statement including the required opinion
24of a physician shall accompany any claim for reimbursement for
25abortions, or induced miscarriages or premature births. This
26statement shall indicate what procedures were used in providing

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1such medical services.
2 Notwithstanding any other law to the contrary, the Illinois
3Department shall, within 365 days after July 22, 2013 (the
4effective date of Public Act 98-104), establish procedures to
5permit skilled care facilities licensed under the Nursing Home
6Care Act to submit monthly billing claims for reimbursement
7purposes. Following development of these procedures, the
8Department shall, by July 1, 2016, test the viability of the
9new system and implement any necessary operational or
10structural changes to its information technology platforms in
11order to allow for the direct acceptance and payment of nursing
12home claims.
13 Notwithstanding any other law to the contrary, the Illinois
14Department shall, within 365 days after August 15, 2014 (the
15effective date of Public Act 98-963), establish procedures to
16permit ID/DD facilities licensed under the ID/DD Community Care
17Act and MC/DD facilities licensed under the MC/DD Act to submit
18monthly billing claims for reimbursement purposes. Following
19development of these procedures, the Department shall have an
20additional 365 days to test the viability of the new system and
21to ensure that any necessary operational or structural changes
22to its information technology platforms are implemented.
23 The Illinois Department shall require all dispensers of
24medical services, other than an individual practitioner or
25group of practitioners, desiring to participate in the Medical
26Assistance program established under this Article to disclose

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1all financial, beneficial, ownership, equity, surety or other
2interests in any and all firms, corporations, partnerships,
3associations, business enterprises, joint ventures, agencies,
4institutions or other legal entities providing any form of
5health care services in this State under this Article.
6 The Illinois Department may require that all dispensers of
7medical services desiring to participate in the medical
8assistance program established under this Article disclose,
9under such terms and conditions as the Illinois Department may
10by rule establish, all inquiries from clients and attorneys
11regarding medical bills paid by the Illinois Department, which
12inquiries could indicate potential existence of claims or liens
13for the Illinois Department.
14 Enrollment of a vendor shall be subject to a provisional
15period and shall be conditional for one year. During the period
16of conditional enrollment, the Department may terminate the
17vendor's eligibility to participate in, or may disenroll the
18vendor from, the medical assistance program without cause.
19Unless otherwise specified, such termination of eligibility or
20disenrollment is not subject to the Department's hearing
21process. However, a disenrolled vendor may reapply without
23 The Department has the discretion to limit the conditional
24enrollment period for vendors based upon category of risk of
25the vendor.
26 Prior to enrollment and during the conditional enrollment

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1period in the medical assistance program, all vendors shall be
2subject to enhanced oversight, screening, and review based on
3the risk of fraud, waste, and abuse that is posed by the
4category of risk of the vendor. The Illinois Department shall
5establish the procedures for oversight, screening, and review,
6which may include, but need not be limited to: criminal and
7financial background checks; fingerprinting; license,
8certification, and authorization verifications; unscheduled or
9unannounced site visits; database checks; prepayment audit
10reviews; audits; payment caps; payment suspensions; and other
11screening as required by federal or State law.
12 The Department shall define or specify the following: (i)
13by provider notice, the "category of risk of the vendor" for
14each type of vendor, which shall take into account the level of
15screening applicable to a particular category of vendor under
16federal law and regulations; (ii) by rule or provider notice,
17the maximum length of the conditional enrollment period for
18each category of risk of the vendor; and (iii) by rule, the
19hearing rights, if any, afforded to a vendor in each category
20of risk of the vendor that is terminated or disenrolled during
21the conditional enrollment period.
22 To be eligible for payment consideration, a vendor's
23payment claim or bill, either as an initial claim or as a
24resubmitted claim following prior rejection, must be received
25by the Illinois Department, or its fiscal intermediary, no
26later than 180 days after the latest date on the claim on which

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1medical goods or services were provided, with the following
3 (1) In the case of a provider whose enrollment is in
4 process by the Illinois Department, the 180-day period
5 shall not begin until the date on the written notice from
6 the Illinois Department that the provider enrollment is
7 complete.
8 (2) In the case of errors attributable to the Illinois
9 Department or any of its claims processing intermediaries
10 which result in an inability to receive, process, or
11 adjudicate a claim, the 180-day period shall not begin
12 until the provider has been notified of the error.
13 (3) In the case of a provider for whom the Illinois
14 Department initiates the monthly billing process.
15 (4) In the case of a provider operated by a unit of
16 local government with a population exceeding 3,000,000
17 when local government funds finance federal participation
18 for claims payments.
19 For claims for services rendered during a period for which
20a recipient received retroactive eligibility, claims must be
21filed within 180 days after the Department determines the
22applicant is eligible. For claims for which the Illinois
23Department is not the primary payer, claims must be submitted
24to the Illinois Department within 180 days after the final
25adjudication by the primary payer.
26 In the case of long term care facilities, within 5 days of

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1receipt by the facility of required prescreening information,
2data for new admissions shall be entered into the Medical
3Electronic Data Interchange (MEDI) or the Recipient
4Eligibility Verification (REV) System or successor system, and
5within 15 days of receipt by the facility of required
6prescreening information, admission documents shall be
7submitted through MEDI or REV or shall be submitted directly to
8the Department of Human Services using required admission
9forms. Effective September 1, 2014, admission documents,
10including all prescreening information, must be submitted
11through MEDI or REV. Confirmation numbers assigned to an
12accepted transaction shall be retained by a facility to verify
13timely submittal. Once an admission transaction has been
14completed, all resubmitted claims following prior rejection
15are subject to receipt no later than 180 days after the
16admission transaction has been completed.
17 Claims that are not submitted and received in compliance
18with the foregoing requirements shall not be eligible for
19payment under the medical assistance program, and the State
20shall have no liability for payment of those claims.
21 To the extent consistent with applicable information and
22privacy, security, and disclosure laws, State and federal
23agencies and departments shall provide the Illinois Department
24access to confidential and other information and data necessary
25to perform eligibility and payment verifications and other
26Illinois Department functions. This includes, but is not

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1limited to: information pertaining to licensure;
2certification; earnings; immigration status; citizenship; wage
3reporting; unearned and earned income; pension income;
4employment; supplemental security income; social security
5numbers; National Provider Identifier (NPI) numbers; the
6National Practitioner Data Bank (NPDB); program and agency
7exclusions; taxpayer identification numbers; tax delinquency;
8corporate information; and death records.
9 The Illinois Department shall enter into agreements with
10State agencies and departments, and is authorized to enter into
11agreements with federal agencies and departments, under which
12such agencies and departments shall share data necessary for
13medical assistance program integrity functions and oversight.
14The Illinois Department shall develop, in cooperation with
15other State departments and agencies, and in compliance with
16applicable federal laws and regulations, appropriate and
17effective methods to share such data. At a minimum, and to the
18extent necessary to provide data sharing, the Illinois
19Department shall enter into agreements with State agencies and
20departments, and is authorized to enter into agreements with
21federal agencies and departments, including but not limited to:
22the Secretary of State; the Department of Revenue; the
23Department of Public Health; the Department of Human Services;
24and the Department of Financial and Professional Regulation.
25 Beginning in fiscal year 2013, the Illinois Department
26shall set forth a request for information to identify the

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1benefits of a pre-payment, post-adjudication, and post-edit
2claims system with the goals of streamlining claims processing
3and provider reimbursement, reducing the number of pending or
4rejected claims, and helping to ensure a more transparent
5adjudication process through the utilization of: (i) provider
6data verification and provider screening technology; and (ii)
7clinical code editing; and (iii) pre-pay, pre- or
8post-adjudicated predictive modeling with an integrated case
9management system with link analysis. Such a request for
10information shall not be considered as a request for proposal
11or as an obligation on the part of the Illinois Department to
12take any action or acquire any products or services.
13 The Illinois Department shall establish policies,
14procedures, standards and criteria by rule for the acquisition,
15repair and replacement of orthotic and prosthetic devices and
16durable medical equipment. Such rules shall provide, but not be
17limited to, the following services: (1) immediate repair or
18replacement of such devices by recipients; and (2) rental,
19lease, purchase or lease-purchase of durable medical equipment
20in a cost-effective manner, taking into consideration the
21recipient's medical prognosis, the extent of the recipient's
22needs, and the requirements and costs for maintaining such
23equipment. Subject to prior approval, such rules shall enable a
24recipient to temporarily acquire and use alternative or
25substitute devices or equipment pending repairs or
26replacements of any device or equipment previously authorized

SB1596- 23 -LRB100 09130 KTG 19284 b
1for such recipient by the Department. Notwithstanding any
2provision of Section 5-5f to the contrary, the Department may,
3by rule, exempt certain replacement wheelchair parts from prior
4approval and, for wheelchairs, wheelchair parts, wheelchair
5accessories, and related seating and positioning items,
6determine the wholesale price by methods other than actual
7acquisition costs.
8 The Department shall require, by rule, all providers of
9durable medical equipment to be accredited by an accreditation
10organization approved by the federal Centers for Medicare and
11Medicaid Services and recognized by the Department in order to
12bill the Department for providing durable medical equipment to
13recipients. No later than 15 months after the effective date of
14the rule adopted pursuant to this paragraph, all providers must
15meet the accreditation requirement.
16 The Department shall execute, relative to the nursing home
17prescreening project, written inter-agency agreements with the
18Department of Human Services and the Department on Aging, to
19effect the following: (i) intake procedures and common
20eligibility criteria for those persons who are receiving
21non-institutional services; and (ii) the establishment and
22development of non-institutional services in areas of the State
23where they are not currently available or are undeveloped; and
24(iii) notwithstanding any other provision of law, subject to
25federal approval, on and after July 1, 2012, an increase in the
26determination of need (DON) scores from 29 to 37 for applicants

SB1596- 24 -LRB100 09130 KTG 19284 b
1for institutional and home and community-based long term care;
2if and only if federal approval is not granted, the Department
3may, in conjunction with other affected agencies, implement
4utilization controls or changes in benefit packages to
5effectuate a similar savings amount for this population; and
6(iv) no later than July 1, 2013, minimum level of care
7eligibility criteria for institutional and home and
8community-based long term care; and (v) no later than October
91, 2013, establish procedures to permit long term care
10providers access to eligibility scores for individuals with an
11admission date who are seeking or receiving services from the
12long term care provider. In order to select the minimum level
13of care eligibility criteria, the Governor shall establish a
14workgroup that includes affected agency representatives and
15stakeholders representing the institutional and home and
16community-based long term care interests. This Section shall
17not restrict the Department from implementing lower level of
18care eligibility criteria for community-based services in
19circumstances where federal approval has been granted.
20 The Illinois Department shall develop and operate, in
21cooperation with other State Departments and agencies and in
22compliance with applicable federal laws and regulations,
23appropriate and effective systems of health care evaluation and
24programs for monitoring of utilization of health care services
25and facilities, as it affects persons eligible for medical
26assistance under this Code.

SB1596- 25 -LRB100 09130 KTG 19284 b
1 The Illinois Department shall report annually to the
2General Assembly, no later than the second Friday in April of
31979 and each year thereafter, in regard to:
4 (a) actual statistics and trends in utilization of
5 medical services by public aid recipients;
6 (b) actual statistics and trends in the provision of
7 the various medical services by medical vendors;
8 (c) current rate structures and proposed changes in
9 those rate structures for the various medical vendors; and
10 (d) efforts at utilization review and control by the
11 Illinois Department.
12 The period covered by each report shall be the 3 years
13ending on the June 30 prior to the report. The report shall
14include suggested legislation for consideration by the General
15Assembly. The filing of one copy of the report with the
16Speaker, one copy with the Minority Leader and one copy with
17the Clerk of the House of Representatives, one copy with the
18President, one copy with the Minority Leader and one copy with
19the Secretary of the Senate, one copy with the Legislative
20Research Unit, and such additional copies with the State
21Government Report Distribution Center for the General Assembly
22as is required under paragraph (t) of Section 7 of the State
23Library Act shall be deemed sufficient to comply with this
25 Rulemaking authority to implement Public Act 95-1045, if
26any, is conditioned on the rules being adopted in accordance

SB1596- 26 -LRB100 09130 KTG 19284 b
1with all provisions of the Illinois Administrative Procedure
2Act and all rules and procedures of the Joint Committee on
3Administrative Rules; any purported rule not so adopted, for
4whatever reason, is unauthorized.
5 On and after July 1, 2012, the Department shall reduce any
6rate of reimbursement for services or other payments or alter
7any methodologies authorized by this Code to reduce any rate of
8reimbursement for services or other payments in accordance with
9Section 5-5e.
10 Because kidney transplantation can be an appropriate, cost
11effective alternative to renal dialysis when medically
12necessary and notwithstanding the provisions of Section 1-11 of
13this Code, beginning October 1, 2014, the Department shall
14cover kidney transplantation for noncitizens with end-stage
15renal disease who are not eligible for comprehensive medical
16benefits, who meet the residency requirements of Section 5-3 of
17this Code, and who would otherwise meet the financial
18requirements of the appropriate class of eligible persons under
19Section 5-2 of this Code. To qualify for coverage of kidney
20transplantation, such person must be receiving emergency renal
21dialysis services covered by the Department. Providers under
22this Section shall be prior approved and certified by the
23Department to perform kidney transplantation and the services
24under this Section shall be limited to services associated with
25kidney transplantation.
26 Notwithstanding any other provision of this Code to the

SB1596- 27 -LRB100 09130 KTG 19284 b
1contrary, on or after July 1, 2017 2015, all FDA approved forms
2of medication assisted treatment prescribed for the treatment
3of alcohol dependence or treatment of opioid dependence shall
4be covered under both fee for service and managed care medical
5assistance programs for persons who are otherwise eligible for
6medical assistance under this Article and may shall not be
7subject to any (1) utilization controls or control, other than
8those established under the American Society of Addiction
9Medicine patient placement criteria, (2) prior authorization
10mandates consistent with the most current edition of the
11American Society of Addiction Medicine's National Practice
12Guideline for the Use of Medications in the Treatment of
13Addiction Involving Opioid Use, as now or hereafter revised, or
14any successor publication mandate, or (3) lifetime restriction
15limit mandate.
16 On or after July 1, 2017 2015, opioid antagonists
17prescribed for the treatment of an opioid overdose, including
18the medication product, administration devices, and any
19pharmacy fees related to the dispensing and administration of
20the opioid antagonist, shall be covered under the medical
21assistance program for persons who are otherwise eligible for
22medical assistance under this Article and may be subject to (1)
23utilization controls or (2) prior authorization mandates
24consistent with the most current edition of the American
25Society of Addiction Medicine's National Practice Guideline
26for the Use of Medications in the Treatment of Addiction

SB1596- 28 -LRB100 09130 KTG 19284 b
1Involving Opioid Use, as now or hereafter revised, or any
2successor publication. As used in this Section, "opioid
3antagonist" means a drug that binds to opioid receptors and
4blocks or inhibits the effect of opioids acting on those
5receptors, including, but not limited to, naloxone
6hydrochloride or any other similarly acting drug approved by
7the U.S. Food and Drug Administration.
8 Upon federal approval, the Department shall provide
9coverage and reimbursement for all drugs that are approved for
10marketing by the federal Food and Drug Administration and that
11are recommended by the federal Public Health Service or the
12United States Centers for Disease Control and Prevention for
13pre-exposure prophylaxis and related pre-exposure prophylaxis
14services, including, but not limited to, HIV and sexually
15transmitted infection screening, treatment for sexually
16transmitted infections, medical monitoring, assorted labs, and
17counseling to reduce the likelihood of HIV infection among
18individuals who are not infected with HIV but who are at high
19risk of HIV infection.
20(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2198-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
228-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
23eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2499-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2520 of P.A. 99-588 for the effective date of P.A. 99-407);
2699-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.

SB1596- 29 -LRB100 09130 KTG 19284 b
17-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
2eff. 1-1-17; revised 9-20-16.)