Bill Amendment: IL HB2589 | 2021-2022 | 102nd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: SUBSTANCE USE DISORDER-OPIOIDS
Status: 2021-08-27 - Public Act . . . . . . . . . 102-0598 [HB2589 Detail]
Download: Illinois-2021-HB2589-Senate_Amendment_001.html
Bill Title: SUBSTANCE USE DISORDER-OPIOIDS
Status: 2021-08-27 - Public Act . . . . . . . . . 102-0598 [HB2589 Detail]
Download: Illinois-2021-HB2589-Senate_Amendment_001.html
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1 | AMENDMENT TO HOUSE BILL 2589
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2 | AMENDMENT NO. ______. Amend House Bill 2589 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Substance Use Disorder Act is amended by | ||||||
5 | changing Sections 5-23 and 20-10 as follows:
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6 | (20 ILCS 301/5-23) | ||||||
7 | Sec. 5-23. Drug Overdose Prevention Program. | ||||||
8 | (a) Reports. | ||||||
9 | (1) The Department may publish annually a report on | ||||||
10 | drug overdose trends statewide that reviews State death | ||||||
11 | rates from available data to ascertain changes in the | ||||||
12 | causes or rates of fatal and nonfatal drug overdose. The | ||||||
13 | report shall also provide information on interventions | ||||||
14 | that would be effective in reducing the rate of fatal or | ||||||
15 | nonfatal drug overdose and on the current substance use | ||||||
16 | disorder treatment capacity within the State. The report |
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1 | shall include an analysis of drug overdose information | ||||||
2 | reported to the Department of Public Health pursuant to | ||||||
3 | subsection (e) of Section 3-3013 of the Counties Code, | ||||||
4 | Section 6.14g of the Hospital Licensing Act, and | ||||||
5 | subsection (j) of Section 22-30 of the School Code. | ||||||
6 | (2) The report may include: | ||||||
7 | (A) Trends in drug overdose death rates. | ||||||
8 | (B) Trends in emergency room utilization related | ||||||
9 | to drug overdose and the cost impact of emergency room | ||||||
10 | utilization. | ||||||
11 | (C) Trends in utilization of pre-hospital and | ||||||
12 | emergency services and the cost impact of emergency | ||||||
13 | services utilization. | ||||||
14 | (D) Suggested improvements in data collection. | ||||||
15 | (E) A description of other interventions effective | ||||||
16 | in reducing the rate of fatal or nonfatal drug | ||||||
17 | overdose. | ||||||
18 | (F) A description of efforts undertaken to educate | ||||||
19 | the public about unused medication and about how to | ||||||
20 | properly dispose of unused medication, including the | ||||||
21 | number of registered collection receptacles in this | ||||||
22 | State, mail-back programs, and drug take-back events. | ||||||
23 | (G) An inventory of the State's substance use | ||||||
24 | disorder treatment capacity, including, but not | ||||||
25 | limited to: | ||||||
26 | (i) The number and type of licensed treatment |
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1 | programs in each geographic area of the State. | ||||||
2 | (ii) The availability of medication-assisted | ||||||
3 | treatment at each licensed program and which types | ||||||
4 | of medication-assisted treatment are available. | ||||||
5 | (iii) The number of recovery homes that accept | ||||||
6 | individuals using medication-assisted treatment in | ||||||
7 | their recovery. | ||||||
8 | (iv) The number of medical professionals | ||||||
9 | currently authorized to prescribe buprenorphine | ||||||
10 | and the number of individuals who fill | ||||||
11 | prescriptions for that medication at retail | ||||||
12 | pharmacies as prescribed. | ||||||
13 | (v) Any partnerships between programs licensed | ||||||
14 | by the Department and other providers of | ||||||
15 | medication-assisted treatment. | ||||||
16 | (vi) Any challenges in providing | ||||||
17 | medication-assisted treatment reported by programs | ||||||
18 | licensed by the Department and any potential | ||||||
19 | solutions. | ||||||
20 | (b) Programs; drug overdose prevention. | ||||||
21 | (1) The Department may establish a program to provide | ||||||
22 | for the production and publication, in electronic and | ||||||
23 | other formats, of drug overdose prevention, recognition, | ||||||
24 | and response literature. The Department may develop and | ||||||
25 | disseminate curricula for use by professionals, | ||||||
26 | organizations, individuals, or committees interested in |
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1 | the prevention of fatal and nonfatal drug overdose, | ||||||
2 | including, but not limited to, drug users, jail and prison | ||||||
3 | personnel, jail and prison inmates, drug treatment | ||||||
4 | professionals, emergency medical personnel, hospital | ||||||
5 | staff, families and associates of drug users, peace | ||||||
6 | officers, firefighters, public safety officers, needle | ||||||
7 | exchange program staff, and other persons. In addition to | ||||||
8 | information regarding drug overdose prevention, | ||||||
9 | recognition, and response, literature produced by the | ||||||
10 | Department shall stress that drug use remains illegal and | ||||||
11 | highly dangerous and that complete abstinence from illegal | ||||||
12 | drug use is the healthiest choice. The literature shall | ||||||
13 | provide information and resources for substance use | ||||||
14 | disorder treatment. | ||||||
15 | The Department may establish or authorize programs for | ||||||
16 | prescribing, dispensing, or distributing opioid | ||||||
17 | antagonists for the treatment of drug overdose. Such | ||||||
18 | programs may include the prescribing of opioid antagonists | ||||||
19 | for the treatment of drug overdose to a person who is not | ||||||
20 | at risk of opioid overdose but who, in the judgment of the | ||||||
21 | health care professional, may be in a position to assist | ||||||
22 | another individual during an opioid-related drug overdose | ||||||
23 | and who has received basic instruction on how to | ||||||
24 | administer an opioid antagonist. | ||||||
25 | (2) The Department may provide advice to State and | ||||||
26 | local officials on the growing drug overdose crisis, |
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1 | including the prevalence of drug overdose incidents, | ||||||
2 | programs promoting the disposal of unused prescription | ||||||
3 | drugs, trends in drug overdose incidents, and solutions to | ||||||
4 | the drug overdose crisis. | ||||||
5 | (3) The Department may support drug overdose | ||||||
6 | prevention, recognition, and response projects by | ||||||
7 | facilitating the acquisition of opioid antagonist | ||||||
8 | medication approved for opioid overdose reversal, | ||||||
9 | facilitating the acquisition of opioid antagonist | ||||||
10 | medication approved for opioid overdose reversal, | ||||||
11 | providing trainings in overdose prevention best practices, | ||||||
12 | connecting programs to medical resources, establishing a | ||||||
13 | statewide standing order for the acquisition of needed | ||||||
14 | medication, establishing learning collaboratives between | ||||||
15 | localities and programs, and assisting programs in | ||||||
16 | navigating any regulatory requirements for establishing or | ||||||
17 | expanding such programs. | ||||||
18 | (4) In supporting best practices in drug overdose | ||||||
19 | prevention programming, the Department may promote the | ||||||
20 | following programmatic elements: | ||||||
21 | (A) Training individuals who currently use drugs | ||||||
22 | in the administration of opioid antagonists approved | ||||||
23 | for the reversal of an opioid overdose. | ||||||
24 | (B) Directly distributing opioid antagonists | ||||||
25 | approved for the reversal of an opioid overdose rather | ||||||
26 | than providing prescriptions to be filled at a |
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1 | pharmacy. | ||||||
2 | (C) Conducting street and community outreach to | ||||||
3 | work directly with individuals who are using drugs. | ||||||
4 | (D) Employing community health workers or peer | ||||||
5 | recovery specialists who are familiar with the | ||||||
6 | communities served and can provide culturally | ||||||
7 | competent services. | ||||||
8 | (E) Collaborating with other community-based | ||||||
9 | organizations, substance use disorder treatment | ||||||
10 | centers, or other health care providers engaged in | ||||||
11 | treating individuals who are using drugs. | ||||||
12 | (F) Providing linkages for individuals to obtain | ||||||
13 | evidence-based substance use disorder treatment. | ||||||
14 | (G) Engaging individuals exiting jails or prisons | ||||||
15 | who are at a high risk of overdose. | ||||||
16 | (H) Providing education and training to | ||||||
17 | community-based organizations who work directly with | ||||||
18 | individuals who are using drugs and those individuals' | ||||||
19 | families and communities. | ||||||
20 | (I) Providing education and training on drug | ||||||
21 | overdose prevention and response to emergency | ||||||
22 | personnel and law enforcement. | ||||||
23 | (J) Informing communities of the important role | ||||||
24 | emergency personnel play in responding to accidental | ||||||
25 | overdose. | ||||||
26 | (K) Producing and distributing targeted mass media |
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1 | materials on drug overdose prevention and response, | ||||||
2 | the potential dangers of leaving unused prescription | ||||||
3 | drugs in the home, and the proper methods for | ||||||
4 | disposing of unused prescription drugs. | ||||||
5 | (c) Grants. | ||||||
6 | (1) The Department may award grants, in accordance | ||||||
7 | with this subsection, to create or support local drug | ||||||
8 | overdose prevention, recognition, and response projects. | ||||||
9 | Local health departments, correctional institutions, | ||||||
10 | hospitals, universities, community-based organizations, | ||||||
11 | and faith-based organizations may apply to the Department | ||||||
12 | for a grant under this subsection at the time and in the | ||||||
13 | manner the Department prescribes. Eligible grant | ||||||
14 | activities include, but are not limited to, purchasing and | ||||||
15 | distributing opioid antagonists, hiring peer recovery | ||||||
16 | specialists or other community members to conduct | ||||||
17 | community outreach, and hosting public health fairs or | ||||||
18 | events to distribute opioid antagonists, promote harm | ||||||
19 | reduction activities, and provide linkages to community | ||||||
20 | partners. | ||||||
21 | (2) In awarding grants, the Department shall consider | ||||||
22 | the overall rate of opioid overdose, the rate of increase | ||||||
23 | in opioid overdose, and racial disparities in opioid | ||||||
24 | overdose experienced by the communities to be served by | ||||||
25 | grantees. The Department necessity for overdose prevention | ||||||
26 | projects in various settings and shall encourage all grant |
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1 | applicants to develop interventions that will be effective | ||||||
2 | and viable in their local areas. | ||||||
3 | (3) (Blank). | ||||||
4 | (3.5) Any hospital licensed under the Hospital | ||||||
5 | Licensing Act or organized under the University of | ||||||
6 | Illinois Hospital Act shall be deemed to
have met the | ||||||
7 | standards and requirements set forth in this Section to | ||||||
8 | enroll in the drug overdose prevention program upon | ||||||
9 | completion of
the enrollment process except that proof of | ||||||
10 | a standing order and attestation of programmatic | ||||||
11 | requirements shall
be waived for enrollment purposes. | ||||||
12 | Reporting mandated by enrollment
shall be necessary to | ||||||
13 | carry out or attain eligibility for associated resources | ||||||
14 | under this Section for drug overdose prevention projects
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15 | operated on the licensed premises of the hospital and | ||||||
16 | operated by the hospital or its designated agent. The | ||||||
17 | Department shall streamline hospital enrollment for drug | ||||||
18 | overdose prevention programs by accepting such deemed | ||||||
19 | status under this Section
in order to reduce barriers to | ||||||
20 | hospital participation in drug overdose prevention, | ||||||
21 | recognition, or response projects. | ||||||
22 | (4) In addition to moneys appropriated by the General | ||||||
23 | Assembly, the Department may seek grants from private | ||||||
24 | foundations, the federal government, and other sources to | ||||||
25 | fund the grants under this Section and to fund an | ||||||
26 | evaluation of the programs supported by the grants. |
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1 | (d) Health care professional prescription of opioid | ||||||
2 | antagonists. | ||||||
3 | (1) A health care professional who, acting in good | ||||||
4 | faith, directly or by standing order, prescribes or | ||||||
5 | dispenses an opioid antagonist to: (a) a patient who, in | ||||||
6 | the judgment of the health care professional, is capable | ||||||
7 | of administering the drug in an emergency, or (b) a person | ||||||
8 | who is not at risk of opioid overdose but who, in the | ||||||
9 | judgment of the health care professional, may be in a | ||||||
10 | position to assist another individual during an | ||||||
11 | opioid-related drug overdose and who has received basic | ||||||
12 | instruction on how to administer an opioid antagonist | ||||||
13 | shall not, as a result of his or her acts or omissions, be | ||||||
14 | subject to: (i) any disciplinary or other adverse action | ||||||
15 | under the Medical Practice Act of 1987, the Physician | ||||||
16 | Assistant Practice Act of 1987, the Nurse Practice Act, | ||||||
17 | the Pharmacy Practice Act, or any other professional | ||||||
18 | licensing statute or (ii) any criminal liability, except | ||||||
19 | for willful and wanton misconduct. | ||||||
20 | (1.5) Notwithstanding any provision of or requirement | ||||||
21 | otherwise imposed by the Pharmacy Practice Act, the | ||||||
22 | Medical Practice Act of 1987, or any other law or rule, | ||||||
23 | including, but not limited to, any requirement related to | ||||||
24 | labeling, storage, or recordkeeping, a health care | ||||||
25 | professional or other person acting under the direction of | ||||||
26 | a health care professional may, directly or by standing |
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1 | order, obtain, store, and dispense an
opioid antagonist to | ||||||
2 | a patient in a facility that includes, but is not limited | ||||||
3 | to, a hospital, a hospital affiliate, or a federally
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4 | qualified health center if the patient information | ||||||
5 | specified in paragraph (4) of this subsection is provided | ||||||
6 | to the patient. A person acting in accordance with this | ||||||
7 | paragraph shall not, as a result of his or her acts or | ||||||
8 | omissions, be subject to: (i) any disciplinary or other | ||||||
9 | adverse action under the Medical Practice Act of 1987, the | ||||||
10 | Physician Assistant Practice Act of 1987, the Nurse | ||||||
11 | Practice Act, the Pharmacy Practice Act, or any other | ||||||
12 | professional licensing statute; or (ii) any criminal | ||||||
13 | liability, except for willful and wanton misconduct. | ||||||
14 | (2) A person who is not otherwise licensed to | ||||||
15 | administer an opioid antagonist may in an emergency | ||||||
16 | administer without fee an opioid antagonist if the person | ||||||
17 | has received the patient information specified in | ||||||
18 | paragraph (4) of this subsection and believes in good | ||||||
19 | faith that another person is experiencing a drug overdose. | ||||||
20 | The person shall not, as a result of his or her acts or | ||||||
21 | omissions, be (i) liable for any violation of the Medical | ||||||
22 | Practice Act of 1987, the Physician Assistant Practice Act | ||||||
23 | of 1987, the Nurse Practice Act, the Pharmacy Practice | ||||||
24 | Act, or any other professional licensing statute, or (ii) | ||||||
25 | subject to any criminal prosecution or civil liability, | ||||||
26 | except for willful and wanton misconduct. |
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1 | (3) A health care professional prescribing an opioid | ||||||
2 | antagonist to a patient shall ensure that the patient | ||||||
3 | receives the patient information specified in paragraph | ||||||
4 | (4) of this subsection. Patient information may be | ||||||
5 | provided by the health care professional or a | ||||||
6 | community-based organization, substance use disorder | ||||||
7 | program, or other organization with which the health care | ||||||
8 | professional establishes a written agreement that includes | ||||||
9 | a description of how the organization will provide patient | ||||||
10 | information, how employees or volunteers providing | ||||||
11 | information will be trained, and standards for documenting | ||||||
12 | the provision of patient information to patients. | ||||||
13 | Provision of patient information shall be documented in | ||||||
14 | the patient's medical record or through similar means as | ||||||
15 | determined by agreement between the health care | ||||||
16 | professional and the organization. The Department, in | ||||||
17 | consultation with statewide organizations representing | ||||||
18 | physicians, pharmacists, advanced practice registered | ||||||
19 | nurses, physician assistants, substance use disorder | ||||||
20 | programs, and other interested groups, shall develop and | ||||||
21 | disseminate to health care professionals, community-based | ||||||
22 | organizations, substance use disorder programs, and other | ||||||
23 | organizations training materials in video, electronic, or | ||||||
24 | other formats to facilitate the provision of such patient | ||||||
25 | information. | ||||||
26 | (4) For the purposes of this subsection: |
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1 | "Opioid antagonist" means a drug that binds to opioid | ||||||
2 | receptors and blocks or inhibits the effect of opioids | ||||||
3 | acting on those receptors, including, but not limited to, | ||||||
4 | naloxone hydrochloride or any other similarly acting drug | ||||||
5 | approved by the U.S. Food and Drug Administration. | ||||||
6 | "Health care professional" means a physician licensed | ||||||
7 | to practice medicine in all its branches, a licensed | ||||||
8 | physician assistant with prescriptive authority, a | ||||||
9 | licensed advanced practice registered nurse with | ||||||
10 | prescriptive authority, an advanced practice registered | ||||||
11 | nurse or physician assistant who practices in a hospital, | ||||||
12 | hospital affiliate, or ambulatory surgical treatment | ||||||
13 | center and possesses appropriate clinical privileges in | ||||||
14 | accordance with the Nurse Practice Act, or a pharmacist | ||||||
15 | licensed to practice pharmacy under the Pharmacy Practice | ||||||
16 | Act. | ||||||
17 | "Patient" includes a person who is not at risk of | ||||||
18 | opioid overdose but who, in the judgment of the physician, | ||||||
19 | advanced practice registered nurse, or physician | ||||||
20 | assistant, may be in a position to assist another | ||||||
21 | individual during an overdose and who has received patient | ||||||
22 | information as required in paragraph (2) of this | ||||||
23 | subsection on the indications for and administration of an | ||||||
24 | opioid antagonist. | ||||||
25 | "Patient information" includes information provided to | ||||||
26 | the patient on drug overdose prevention and recognition; |
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1 | how to perform rescue breathing and resuscitation; opioid | ||||||
2 | antagonist dosage and administration; the importance of | ||||||
3 | calling 911; care for the overdose victim after | ||||||
4 | administration of the overdose antagonist; and other | ||||||
5 | issues as necessary.
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6 | (e) Drug overdose response policy. | ||||||
7 | (1) Every State and local government agency that | ||||||
8 | employs a law enforcement officer or fireman as those | ||||||
9 | terms are defined in the Line of Duty Compensation Act | ||||||
10 | must possess opioid antagonists and must establish a | ||||||
11 | policy to control the acquisition, storage, | ||||||
12 | transportation, and administration of such opioid | ||||||
13 | antagonists and to provide training in the administration | ||||||
14 | of opioid antagonists. A State or local government agency | ||||||
15 | that employs a fireman as defined in the Line of Duty | ||||||
16 | Compensation Act but does not respond to emergency medical | ||||||
17 | calls or provide medical services shall be exempt from | ||||||
18 | this subsection. | ||||||
19 | (2) Every publicly or privately owned ambulance, | ||||||
20 | special emergency medical services vehicle, non-transport | ||||||
21 | vehicle, or ambulance assist vehicle, as described in the | ||||||
22 | Emergency Medical Services (EMS) Systems Act, that | ||||||
23 | responds to requests for emergency services or transports | ||||||
24 | patients between hospitals in emergency situations must | ||||||
25 | possess opioid antagonists. | ||||||
26 | (3) Entities that are required under paragraphs (1) |
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1 | and (2) to possess opioid antagonists may also apply to | ||||||
2 | the Department for a grant to fund the acquisition of | ||||||
3 | opioid antagonists and training programs on the | ||||||
4 | administration of opioid antagonists. | ||||||
5 | (Source: P.A. 100-201, eff. 8-18-17; 100-513, eff. 1-1-18; | ||||||
6 | 100-759, eff. 1-1-19; 101-356, eff. 8-9-19.)
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7 | (20 ILCS 301/20-10)
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8 | Sec. 20-10. Screening, Brief Intervention, and Referral to | ||||||
9 | Treatment. As used in this Section, "SBIRT" means a | ||||||
10 | comprehensive, integrated, public health approach to the | ||||||
11 | delivery of early intervention and treatment
services for | ||||||
12 | persons who are at risk of developing substance use disorders | ||||||
13 | or have substance use disorders including, but not limited to, | ||||||
14 | an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT | ||||||
15 | services include all of the following: | ||||||
16 | (1) Screening to quickly assess the severity of | ||||||
17 | substance use and to identify the appropriate level of | ||||||
18 | treatment. | ||||||
19 | (2) Brief intervention focused on increasing insight | ||||||
20 | and awareness regarding substance use and motivation | ||||||
21 | toward behavioral change. | ||||||
22 | (3) Referral to treatment provided to those identified | ||||||
23 | as needing more extensive treatment with access to | ||||||
24 | specialty care. | ||||||
25 | SBIRT services may include, but are not limited to, the |
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1 | following settings and programs: primary care centers, | ||||||
2 | hospital emergency rooms, hospital in-patient units,
trauma | ||||||
3 | centers, community behavioral health programs, and other | ||||||
4 | community settings that provide opportunities for early | ||||||
5 | intervention with at-risk substance users before more severe
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6 | consequences occur. | ||||||
7 | (a) As used in this Section, "SBIRT" means the | ||||||
8 | identification of individuals, within primary care settings, | ||||||
9 | who need substance use disorder treatment. Primary care | ||||||
10 | providers will screen and, based on the results of the screen, | ||||||
11 | deliver a brief intervention or make referral to a licensed | ||||||
12 | treatment provider as appropriate. SBIRT is not a licensed | ||||||
13 | category of service. | ||||||
14 | (b) The Department may develop policy or best practice | ||||||
15 | guidelines for identification of at-risk individuals through | ||||||
16 | SBIRT and contract or billing requirements for SBIRT.
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17 | (Source: P.A. 100-759, eff. 1-1-19 .)
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18 | Section 10. The Illinois Public Aid Code is amended by | ||||||
19 | changing Section 5-5 and by adding Section 5-41 as follows:
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20 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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21 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
22 | rule, shall
determine the quantity and quality of and the rate | ||||||
23 | of reimbursement for the
medical assistance for which
payment | ||||||
24 | will be authorized, and the medical services to be provided,
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1 | which may include all or part of the following: (1) inpatient | ||||||
2 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
3 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
4 | services; (5) physicians'
services whether furnished in the | ||||||
5 | office, the patient's home, a
hospital, a skilled nursing | ||||||
6 | home, or elsewhere; (6) medical care, or any
other type of | ||||||
7 | remedial care furnished by licensed practitioners; (7)
home | ||||||
8 | health care services; (8) private duty nursing service; (9) | ||||||
9 | clinic
services; (10) dental services, including prevention | ||||||
10 | and treatment of periodontal disease and dental caries disease | ||||||
11 | for pregnant women, provided by an individual licensed to | ||||||
12 | practice dentistry or dental surgery; for purposes of this | ||||||
13 | item (10), "dental services" means diagnostic, preventive, or | ||||||
14 | corrective procedures provided by or under the supervision of | ||||||
15 | a dentist in the practice of his or her profession; (11) | ||||||
16 | physical therapy and related
services; (12) prescribed drugs, | ||||||
17 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
18 | a physician skilled in the diseases of the eye,
or by an | ||||||
19 | optometrist, whichever the person may select; (13) other
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20 | diagnostic, screening, preventive, and rehabilitative | ||||||
21 | services, including to ensure that the individual's need for | ||||||
22 | intervention or treatment of mental disorders or substance use | ||||||
23 | disorders or co-occurring mental health and substance use | ||||||
24 | disorders is determined using a uniform screening, assessment, | ||||||
25 | and evaluation process inclusive of criteria, for children and | ||||||
26 | adults; for purposes of this item (13), a uniform screening, |
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1 | assessment, and evaluation process refers to a process that | ||||||
2 | includes an appropriate evaluation and, as warranted, a | ||||||
3 | referral; "uniform" does not mean the use of a singular | ||||||
4 | instrument, tool, or process that all must utilize; (14)
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5 | transportation and such other expenses as may be necessary; | ||||||
6 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
7 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
8 | Treatment Act, for
injuries sustained as a result of the | ||||||
9 | sexual assault, including
examinations and laboratory tests to | ||||||
10 | discover evidence which may be used in
criminal proceedings | ||||||
11 | arising from the sexual assault; (16) the
diagnosis and | ||||||
12 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
13 | care, and any other type of remedial care recognized
under the | ||||||
14 | laws of this State. The term "any other type of remedial care" | ||||||
15 | shall
include nursing care and nursing home service for | ||||||
16 | persons who rely on
treatment by spiritual means alone through | ||||||
17 | prayer for healing.
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18 | Notwithstanding any other provision of this Section, a | ||||||
19 | comprehensive
tobacco use cessation program that includes | ||||||
20 | purchasing prescription drugs or
prescription medical devices | ||||||
21 | approved by the Food and Drug Administration shall
be covered | ||||||
22 | under the medical assistance
program under this Article for | ||||||
23 | persons who are otherwise eligible for
assistance under this | ||||||
24 | Article.
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25 | Notwithstanding any other provision of this Code, | ||||||
26 | reproductive health care that is otherwise legal in Illinois |
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1 | shall be covered under the medical assistance program for | ||||||
2 | persons who are otherwise eligible for medical assistance | ||||||
3 | under this Article. | ||||||
4 | Notwithstanding any other provision of this Code, the | ||||||
5 | Illinois
Department may not require, as a condition of payment | ||||||
6 | for any laboratory
test authorized under this Article, that a | ||||||
7 | physician's handwritten signature
appear on the laboratory | ||||||
8 | test order form. The Illinois Department may,
however, impose | ||||||
9 | other appropriate requirements regarding laboratory test
order | ||||||
10 | documentation.
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11 | Upon receipt of federal approval of an amendment to the | ||||||
12 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
13 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
14 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
15 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
16 | that its vendor or vendors are enrolled as providers in the | ||||||
17 | medical assistance program and in any capitated Medicaid | ||||||
18 | managed care entity (MCE) serving individuals enrolled in a | ||||||
19 | school within the CPS system. Under any contract procured | ||||||
20 | under this provision, the vendor or vendors must serve only | ||||||
21 | individuals enrolled in a school within the CPS system. Claims | ||||||
22 | for services provided by CPS's vendor or vendors to recipients | ||||||
23 | of benefits in the medical assistance program under this Code, | ||||||
24 | the Children's Health Insurance Program, or the Covering ALL | ||||||
25 | KIDS Health Insurance Program shall be submitted to the | ||||||
26 | Department or the MCE in which the individual is enrolled for |
| |||||||
| |||||||
1 | payment and shall be reimbursed at the Department's or the | ||||||
2 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
3 | On and after July 1, 2012, the Department of Healthcare | ||||||
4 | and Family Services may provide the following services to
| ||||||
5 | persons
eligible for assistance under this Article who are | ||||||
6 | participating in
education, training or employment programs | ||||||
7 | operated by the Department of Human
Services as successor to | ||||||
8 | the Department of Public Aid:
| ||||||
9 | (1) dental services provided by or under the | ||||||
10 | supervision of a dentist; and
| ||||||
11 | (2) eyeglasses prescribed by a physician skilled in | ||||||
12 | the diseases of the
eye, or by an optometrist, whichever | ||||||
13 | the person may select.
| ||||||
14 | On and after July 1, 2018, the Department of Healthcare | ||||||
15 | and Family Services shall provide dental services to any adult | ||||||
16 | who is otherwise eligible for assistance under the medical | ||||||
17 | assistance program. As used in this paragraph, "dental | ||||||
18 | services" means diagnostic, preventative, restorative, or | ||||||
19 | corrective procedures, including procedures and services for | ||||||
20 | the prevention and treatment of periodontal disease and dental | ||||||
21 | caries disease, provided by an individual who is licensed to | ||||||
22 | practice dentistry or dental surgery or who is under the | ||||||
23 | supervision of a dentist in the practice of his or her | ||||||
24 | profession. | ||||||
25 | On and after July 1, 2018, targeted dental services, as | ||||||
26 | set forth in Exhibit D of the Consent Decree entered by the |
| |||||||
| |||||||
1 | United States District Court for the Northern District of | ||||||
2 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
3 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
4 | the medical assistance program shall be established at no less | ||||||
5 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
6 | of the Consent Decree for targeted dental services that are | ||||||
7 | provided to persons under the age of 18 under the medical | ||||||
8 | assistance program. | ||||||
9 | Notwithstanding any other provision of this Code and | ||||||
10 | subject to federal approval, the Department may adopt rules to | ||||||
11 | allow a dentist who is volunteering his or her service at no | ||||||
12 | cost to render dental services through an enrolled | ||||||
13 | not-for-profit health clinic without the dentist personally | ||||||
14 | enrolling as a participating provider in the medical | ||||||
15 | assistance program. A not-for-profit health clinic shall | ||||||
16 | include a public health clinic or Federally Qualified Health | ||||||
17 | Center or other enrolled provider, as determined by the | ||||||
18 | Department, through which dental services covered under this | ||||||
19 | Section are performed. The Department shall establish a | ||||||
20 | process for payment of claims for reimbursement for covered | ||||||
21 | dental services rendered under this provision. | ||||||
22 | The Illinois Department, by rule, may distinguish and | ||||||
23 | classify the
medical services to be provided only in | ||||||
24 | accordance with the classes of
persons designated in Section | ||||||
25 | 5-2.
| ||||||
26 | The Department of Healthcare and Family Services must |
| |||||||
| |||||||
1 | provide coverage and reimbursement for amino acid-based | ||||||
2 | elemental formulas, regardless of delivery method, for the | ||||||
3 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
4 | short bowel syndrome when the prescribing physician has issued | ||||||
5 | a written order stating that the amino acid-based elemental | ||||||
6 | formula is medically necessary.
| ||||||
7 | The Illinois Department shall authorize the provision of, | ||||||
8 | and shall
authorize payment for, screening by low-dose | ||||||
9 | mammography for the presence of
occult breast cancer for women | ||||||
10 | 35 years of age or older who are eligible
for medical | ||||||
11 | assistance under this Article, as follows: | ||||||
12 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
13 | age.
| ||||||
14 | (B) An annual mammogram for women 40 years of age or | ||||||
15 | older. | ||||||
16 | (C) A mammogram at the age and intervals considered | ||||||
17 | medically necessary by the woman's health care provider | ||||||
18 | for women under 40 years of age and having a family history | ||||||
19 | of breast cancer, prior personal history of breast cancer, | ||||||
20 | positive genetic testing, or other risk factors. | ||||||
21 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
22 | entire breast or breasts if a mammogram demonstrates | ||||||
23 | heterogeneous or dense breast tissue or when medically | ||||||
24 | necessary as determined by a physician licensed to | ||||||
25 | practice medicine in all of its branches. | ||||||
26 | (E) A screening MRI when medically necessary, as |
| |||||||
| |||||||
1 | determined by a physician licensed to practice medicine in | ||||||
2 | all of its branches. | ||||||
3 | (F) A diagnostic mammogram when medically necessary, | ||||||
4 | as determined by a physician licensed to practice medicine | ||||||
5 | in all its branches, advanced practice registered nurse, | ||||||
6 | or physician assistant. | ||||||
7 | The Department shall not impose a deductible, coinsurance, | ||||||
8 | copayment, or any other cost-sharing requirement on the | ||||||
9 | coverage provided under this paragraph; except that this | ||||||
10 | sentence does not apply to coverage of diagnostic mammograms | ||||||
11 | to the extent such coverage would disqualify a high-deductible | ||||||
12 | health plan from eligibility for a health savings account | ||||||
13 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
14 | U.S.C. 223). | ||||||
15 | All screenings
shall
include a physical breast exam, | ||||||
16 | instruction on self-examination and
information regarding the | ||||||
17 | frequency of self-examination and its value as a
preventative | ||||||
18 | tool. | ||||||
19 | For purposes of this Section: | ||||||
20 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
21 | diagnostic mammography. | ||||||
22 | "Diagnostic
mammography" means a method of screening that | ||||||
23 | is designed to
evaluate an abnormality in a breast, including | ||||||
24 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
25 | subjective or objective
abnormality otherwise detected in the | ||||||
26 | breast. |
| |||||||
| |||||||
1 | "Low-dose mammography" means
the x-ray examination of the | ||||||
2 | breast using equipment dedicated specifically
for mammography, | ||||||
3 | including the x-ray tube, filter, compression device,
and | ||||||
4 | image receptor, with an average radiation exposure delivery
of | ||||||
5 | less than one rad per breast for 2 views of an average size | ||||||
6 | breast.
The term also includes digital mammography and | ||||||
7 | includes breast tomosynthesis. | ||||||
8 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
9 | involves the acquisition of projection images over the | ||||||
10 | stationary breast to produce cross-sectional digital | ||||||
11 | three-dimensional images of the breast. | ||||||
12 | If, at any time, the Secretary of the United States | ||||||
13 | Department of Health and Human Services, or its successor | ||||||
14 | agency, promulgates rules or regulations to be published in | ||||||
15 | the Federal Register or publishes a comment in the Federal | ||||||
16 | Register or issues an opinion, guidance, or other action that | ||||||
17 | would require the State, pursuant to any provision of the | ||||||
18 | Patient Protection and Affordable Care Act (Public Law | ||||||
19 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
20 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
21 | of any coverage for breast tomosynthesis outlined in this | ||||||
22 | paragraph, then the requirement that an insurer cover breast | ||||||
23 | tomosynthesis is inoperative other than any such coverage | ||||||
24 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
25 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
26 | for the cost of coverage for breast tomosynthesis set forth in |
| |||||||
| |||||||
1 | this paragraph.
| ||||||
2 | On and after January 1, 2016, the Department shall ensure | ||||||
3 | that all networks of care for adult clients of the Department | ||||||
4 | include access to at least one breast imaging Center of | ||||||
5 | Imaging Excellence as certified by the American College of | ||||||
6 | Radiology. | ||||||
7 | On and after January 1, 2012, providers participating in a | ||||||
8 | quality improvement program approved by the Department shall | ||||||
9 | be reimbursed for screening and diagnostic mammography at the | ||||||
10 | same rate as the Medicare program's rates, including the | ||||||
11 | increased reimbursement for digital mammography. | ||||||
12 | The Department shall convene an expert panel including | ||||||
13 | representatives of hospitals, free-standing mammography | ||||||
14 | facilities, and doctors, including radiologists, to establish | ||||||
15 | quality standards for mammography. | ||||||
16 | On and after January 1, 2017, providers participating in a | ||||||
17 | breast cancer treatment quality improvement program approved | ||||||
18 | by the Department shall be reimbursed for breast cancer | ||||||
19 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
20 | program's rates for the data elements included in the breast | ||||||
21 | cancer treatment quality program. | ||||||
22 | The Department shall convene an expert panel, including | ||||||
23 | representatives of hospitals, free-standing breast cancer | ||||||
24 | treatment centers, breast cancer quality organizations, and | ||||||
25 | doctors, including breast surgeons, reconstructive breast | ||||||
26 | surgeons, oncologists, and primary care providers to establish |
| |||||||
| |||||||
1 | quality standards for breast cancer treatment. | ||||||
2 | Subject to federal approval, the Department shall | ||||||
3 | establish a rate methodology for mammography at federally | ||||||
4 | qualified health centers and other encounter-rate clinics. | ||||||
5 | These clinics or centers may also collaborate with other | ||||||
6 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
7 | Department shall report to the General Assembly on the status | ||||||
8 | of the provision set forth in this paragraph. | ||||||
9 | The Department shall establish a methodology to remind | ||||||
10 | women who are age-appropriate for screening mammography, but | ||||||
11 | who have not received a mammogram within the previous 18 | ||||||
12 | months, of the importance and benefit of screening | ||||||
13 | mammography. The Department shall work with experts in breast | ||||||
14 | cancer outreach and patient navigation to optimize these | ||||||
15 | reminders and shall establish a methodology for evaluating | ||||||
16 | their effectiveness and modifying the methodology based on the | ||||||
17 | evaluation. | ||||||
18 | The Department shall establish a performance goal for | ||||||
19 | primary care providers with respect to their female patients | ||||||
20 | over age 40 receiving an annual mammogram. This performance | ||||||
21 | goal shall be used to provide additional reimbursement in the | ||||||
22 | form of a quality performance bonus to primary care providers | ||||||
23 | who meet that goal. | ||||||
24 | The Department shall devise a means of case-managing or | ||||||
25 | patient navigation for beneficiaries diagnosed with breast | ||||||
26 | cancer. This program shall initially operate as a pilot |
| |||||||
| |||||||
1 | program in areas of the State with the highest incidence of | ||||||
2 | mortality related to breast cancer. At least one pilot program | ||||||
3 | site shall be in the metropolitan Chicago area and at least one | ||||||
4 | site shall be outside the metropolitan Chicago area. On or | ||||||
5 | after July 1, 2016, the pilot program shall be expanded to | ||||||
6 | include one site in western Illinois, one site in southern | ||||||
7 | Illinois, one site in central Illinois, and 4 sites within | ||||||
8 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
9 | be carried out measuring health outcomes and cost of care for | ||||||
10 | those served by the pilot program compared to similarly | ||||||
11 | situated patients who are not served by the pilot program. | ||||||
12 | The Department shall require all networks of care to | ||||||
13 | develop a means either internally or by contract with experts | ||||||
14 | in navigation and community outreach to navigate cancer | ||||||
15 | patients to comprehensive care in a timely fashion. The | ||||||
16 | Department shall require all networks of care to include | ||||||
17 | access for patients diagnosed with cancer to at least one | ||||||
18 | academic commission on cancer-accredited cancer program as an | ||||||
19 | in-network covered benefit. | ||||||
20 | Any medical or health care provider shall immediately | ||||||
21 | recommend, to
any pregnant woman who is being provided | ||||||
22 | prenatal services and is suspected
of having a substance use | ||||||
23 | disorder as defined in the Substance Use Disorder Act, | ||||||
24 | referral to a local substance use disorder treatment program | ||||||
25 | licensed by the Department of Human Services or to a licensed
| ||||||
26 | hospital which provides substance abuse treatment services. |
| |||||||
| |||||||
1 | The Department of Healthcare and Family Services
shall assure | ||||||
2 | coverage for the cost of treatment of the drug abuse or
| ||||||
3 | addiction for pregnant recipients in accordance with the | ||||||
4 | Illinois Medicaid
Program in conjunction with the Department | ||||||
5 | of Human Services.
| ||||||
6 | All medical providers providing medical assistance to | ||||||
7 | pregnant women
under this Code shall receive information from | ||||||
8 | the Department on the
availability of services under any
| ||||||
9 | program providing case management services for addicted women,
| ||||||
10 | including information on appropriate referrals for other | ||||||
11 | social services
that may be needed by addicted women in | ||||||
12 | addition to treatment for addiction.
| ||||||
13 | The Illinois Department, in cooperation with the | ||||||
14 | Departments of Human
Services (as successor to the Department | ||||||
15 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
16 | a public awareness campaign, may
provide information | ||||||
17 | concerning treatment for alcoholism and drug abuse and
| ||||||
18 | addiction, prenatal health care, and other pertinent programs | ||||||
19 | directed at
reducing the number of drug-affected infants born | ||||||
20 | to recipients of medical
assistance.
| ||||||
21 | Neither the Department of Healthcare and Family Services | ||||||
22 | nor the Department of Human
Services shall sanction the | ||||||
23 | recipient solely on the basis of
her substance abuse.
| ||||||
24 | The Illinois Department shall establish such regulations | ||||||
25 | governing
the dispensing of health services under this Article | ||||||
26 | as it shall deem
appropriate. The Department
should
seek the |
| |||||||
| |||||||
1 | advice of formal professional advisory committees appointed by
| ||||||
2 | the Director of the Illinois Department for the purpose of | ||||||
3 | providing regular
advice on policy and administrative matters, | ||||||
4 | information dissemination and
educational activities for | ||||||
5 | medical and health care providers, and
consistency in | ||||||
6 | procedures to the Illinois Department.
| ||||||
7 | The Illinois Department may develop and contract with | ||||||
8 | Partnerships of
medical providers to arrange medical services | ||||||
9 | for persons eligible under
Section 5-2 of this Code. | ||||||
10 | Implementation of this Section may be by
demonstration | ||||||
11 | projects in certain geographic areas. The Partnership shall
be | ||||||
12 | represented by a sponsor organization. The Department, by | ||||||
13 | rule, shall
develop qualifications for sponsors of | ||||||
14 | Partnerships. Nothing in this
Section shall be construed to | ||||||
15 | require that the sponsor organization be a
medical | ||||||
16 | organization.
| ||||||
17 | The sponsor must negotiate formal written contracts with | ||||||
18 | medical
providers for physician services, inpatient and | ||||||
19 | outpatient hospital care,
home health services, treatment for | ||||||
20 | alcoholism and substance abuse, and
other services determined | ||||||
21 | necessary by the Illinois Department by rule for
delivery by | ||||||
22 | Partnerships. Physician services must include prenatal and
| ||||||
23 | obstetrical care. The Illinois Department shall reimburse | ||||||
24 | medical services
delivered by Partnership providers to clients | ||||||
25 | in target areas according to
provisions of this Article and | ||||||
26 | the Illinois Health Finance Reform Act,
except that:
|
| |||||||
| |||||||
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 | ||||||
4 | the Partnership may receive an additional surcharge
for | ||||||
5 | such 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 | ||||||
14 | qualifications to
participate in Partnerships to ensure the | ||||||
15 | delivery of high quality medical
services. These | ||||||
16 | qualifications shall be determined by rule of the Illinois
| ||||||
17 | Department and may be higher than qualifications for | ||||||
18 | participation in the
medical assistance program. Partnership | ||||||
19 | sponsors may prescribe reasonable
additional qualifications | ||||||
20 | for participation by medical providers, only with
the prior | ||||||
21 | written approval of the Illinois Department.
| ||||||
22 | Nothing in this Section shall limit the free choice of | ||||||
23 | practitioners,
hospitals, and other providers of medical | ||||||
24 | services by clients.
In order to ensure patient freedom of | ||||||
25 | choice, the Illinois Department shall
immediately promulgate | ||||||
26 | all rules and take all other necessary actions so that
|
| |||||||
| |||||||
1 | provided services may be accessed from therapeutically | ||||||
2 | certified optometrists
to the full extent of the Illinois | ||||||
3 | Optometric Practice Act of 1987 without
discriminating between | ||||||
4 | service providers.
| ||||||
5 | The Department shall apply for a waiver from the United | ||||||
6 | States Health
Care Financing Administration to allow for the | ||||||
7 | implementation of
Partnerships under this Section.
| ||||||
8 | The Illinois Department shall require health care | ||||||
9 | providers to maintain
records that document the medical care | ||||||
10 | and services provided to recipients
of Medical Assistance | ||||||
11 | under this Article. Such records must be retained for a period | ||||||
12 | of not less than 6 years from the date of service or as | ||||||
13 | provided by applicable State law, whichever period is longer, | ||||||
14 | except that if an audit is initiated within the required | ||||||
15 | retention period then the records must be retained until the | ||||||
16 | audit is completed and every exception is resolved. The | ||||||
17 | Illinois Department shall
require health care providers to | ||||||
18 | make available, when authorized by the
patient, in writing, | ||||||
19 | the medical records in a timely fashion to other
health care | ||||||
20 | providers who are treating or serving persons eligible for
| ||||||
21 | Medical Assistance under this Article. All dispensers of | ||||||
22 | medical services
shall be required to maintain and retain | ||||||
23 | business and professional records
sufficient to fully and | ||||||
24 | accurately document the nature, scope, details and
receipt of | ||||||
25 | the health care provided to persons eligible for medical
| ||||||
26 | assistance under this Code, in accordance with regulations |
| |||||||
| |||||||
1 | promulgated by
the Illinois Department. The rules and | ||||||
2 | regulations shall require that proof
of the receipt of | ||||||
3 | prescription drugs, dentures, prosthetic devices and
| ||||||
4 | eyeglasses by eligible persons under this Section accompany | ||||||
5 | each claim
for reimbursement submitted by the dispenser of | ||||||
6 | such medical services.
No such claims for reimbursement shall | ||||||
7 | be approved for payment by the Illinois
Department without | ||||||
8 | such proof of receipt, unless the Illinois Department
shall | ||||||
9 | have put into effect and shall be operating a system of | ||||||
10 | post-payment
audit and review which shall, on a sampling | ||||||
11 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
12 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
13 | for which payment is being made are actually being
received by | ||||||
14 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
15 | (the effective date of Public Act 83-1439), the Illinois | ||||||
16 | Department shall establish a
current list of acquisition costs | ||||||
17 | for all prosthetic devices and any
other items recognized as | ||||||
18 | medical equipment and supplies reimbursable under
this Article | ||||||
19 | and shall update such list on a quarterly basis, except that
| ||||||
20 | the acquisition costs of all prescription drugs shall be | ||||||
21 | updated no
less frequently than every 30 days as required by | ||||||
22 | Section 5-5.12.
| ||||||
23 | Notwithstanding any other law to the contrary, the | ||||||
24 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
25 | (the effective date of Public Act 98-104), establish | ||||||
26 | procedures to permit skilled care facilities licensed under |
| |||||||
| |||||||
1 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
2 | reimbursement purposes. Following development of these | ||||||
3 | procedures, the Department shall, by July 1, 2016, test the | ||||||
4 | viability of the new system and implement any necessary | ||||||
5 | operational or structural changes to its information | ||||||
6 | technology platforms in order to allow for the direct | ||||||
7 | acceptance and payment of nursing home claims. | ||||||
8 | Notwithstanding any other law to the contrary, the | ||||||
9 | Illinois Department shall, within 365 days after August 15, | ||||||
10 | 2014 (the effective date of Public Act 98-963), establish | ||||||
11 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
12 | Community Care Act and MC/DD facilities licensed under the | ||||||
13 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
14 | purposes. Following development of these procedures, the | ||||||
15 | Department shall have an additional 365 days to test the | ||||||
16 | viability of the new system and to ensure that any necessary | ||||||
17 | operational or structural changes to its information | ||||||
18 | technology platforms are implemented. | ||||||
19 | The Illinois Department shall require all dispensers of | ||||||
20 | medical
services, other than an individual practitioner or | ||||||
21 | group of practitioners,
desiring to participate in the Medical | ||||||
22 | Assistance program
established under this Article to disclose | ||||||
23 | all financial, beneficial,
ownership, equity, surety or other | ||||||
24 | interests in any and all firms,
corporations, partnerships, | ||||||
25 | associations, business enterprises, joint
ventures, agencies, | ||||||
26 | institutions or other legal entities providing any
form of |
| |||||||
| |||||||
1 | health care services in this State under this Article.
| ||||||
2 | The Illinois Department may require that all dispensers of | ||||||
3 | medical
services desiring to participate in the medical | ||||||
4 | assistance program
established under this Article disclose, | ||||||
5 | under such terms and conditions as
the Illinois Department may | ||||||
6 | by rule establish, all inquiries from clients
and attorneys | ||||||
7 | regarding medical bills paid by the Illinois Department, which
| ||||||
8 | inquiries could indicate potential existence of claims or | ||||||
9 | liens for the
Illinois Department.
| ||||||
10 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
11 | period and shall be conditional for one year. During the | ||||||
12 | period of conditional enrollment, the Department may
terminate | ||||||
13 | the vendor's eligibility to participate in, or may disenroll | ||||||
14 | the vendor from, the medical assistance
program without cause. | ||||||
15 | Unless otherwise specified, such termination of eligibility or | ||||||
16 | disenrollment is not subject to the
Department's hearing | ||||||
17 | process.
However, a disenrolled vendor may reapply without | ||||||
18 | penalty.
| ||||||
19 | The Department has the discretion to limit the conditional | ||||||
20 | enrollment period for vendors based upon category of risk of | ||||||
21 | the vendor. | ||||||
22 | Prior to enrollment and during the conditional enrollment | ||||||
23 | period in the medical assistance program, all vendors shall be | ||||||
24 | subject to enhanced oversight, screening, and review based on | ||||||
25 | the risk of fraud, waste, and abuse that is posed by the | ||||||
26 | category of risk of the vendor. The Illinois Department shall |
| |||||||
| |||||||
1 | establish the procedures for oversight, screening, and review, | ||||||
2 | which may include, but need not be limited to: criminal and | ||||||
3 | financial background checks; fingerprinting; license, | ||||||
4 | certification, and authorization verifications; unscheduled or | ||||||
5 | unannounced site visits; database checks; prepayment audit | ||||||
6 | reviews; audits; payment caps; payment suspensions; and other | ||||||
7 | screening as required by federal or State law. | ||||||
8 | The Department shall define or specify the following: (i) | ||||||
9 | by provider notice, the "category of risk of the vendor" for | ||||||
10 | each type of vendor, which shall take into account the level of | ||||||
11 | screening applicable to a particular category of vendor under | ||||||
12 | federal law and regulations; (ii) by rule or provider notice, | ||||||
13 | the maximum length of the conditional enrollment period for | ||||||
14 | each category of risk of the vendor; and (iii) by rule, the | ||||||
15 | hearing rights, if any, afforded to a vendor in each category | ||||||
16 | of risk of the vendor that is terminated or disenrolled during | ||||||
17 | the conditional enrollment period. | ||||||
18 | To be eligible for payment consideration, a vendor's | ||||||
19 | payment claim or bill, either as an initial claim or as a | ||||||
20 | resubmitted claim following prior rejection, must be received | ||||||
21 | by the Illinois Department, or its fiscal intermediary, no | ||||||
22 | later than 180 days after the latest date on the claim on which | ||||||
23 | medical goods or services were provided, with the following | ||||||
24 | exceptions: | ||||||
25 | (1) In the case of a provider whose enrollment is in | ||||||
26 | process by the Illinois Department, the 180-day period |
| |||||||
| |||||||
1 | shall not begin until the date on the written notice from | ||||||
2 | the Illinois Department that the provider enrollment is | ||||||
3 | complete. | ||||||
4 | (2) In the case of errors attributable to the Illinois | ||||||
5 | Department or any of its claims processing intermediaries | ||||||
6 | which result in an inability to receive, process, or | ||||||
7 | adjudicate a claim, the 180-day period shall not begin | ||||||
8 | until the provider has been notified of the error. | ||||||
9 | (3) In the case of a provider for whom the Illinois | ||||||
10 | Department initiates the monthly billing process. | ||||||
11 | (4) In the case of a provider operated by a unit of | ||||||
12 | local government with a population exceeding 3,000,000 | ||||||
13 | when local government funds finance federal participation | ||||||
14 | for claims payments. | ||||||
15 | For claims for services rendered during a period for which | ||||||
16 | a recipient received retroactive eligibility, claims must be | ||||||
17 | filed within 180 days after the Department determines the | ||||||
18 | applicant is eligible. For claims for which the Illinois | ||||||
19 | Department is not the primary payer, claims must be submitted | ||||||
20 | to the Illinois Department within 180 days after the final | ||||||
21 | adjudication by the primary payer. | ||||||
22 | In the case of long term care facilities, within 45 | ||||||
23 | calendar days of receipt by the facility of required | ||||||
24 | prescreening information, new admissions with associated | ||||||
25 | admission documents shall be submitted through the Medical | ||||||
26 | Electronic Data Interchange (MEDI) or the Recipient |
| |||||||
| |||||||
1 | Eligibility Verification (REV) System or shall be submitted | ||||||
2 | directly to the Department of Human Services using required | ||||||
3 | admission forms. Effective September
1, 2014, admission | ||||||
4 | documents, including all prescreening
information, must be | ||||||
5 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
6 | to an accepted transaction shall be retained by a facility to | ||||||
7 | verify timely submittal. Once an admission transaction has | ||||||
8 | been completed, all resubmitted claims following prior | ||||||
9 | rejection are subject to receipt no later than 180 days after | ||||||
10 | the admission transaction has been completed. | ||||||
11 | Claims that are not submitted and received in compliance | ||||||
12 | with the foregoing requirements shall not be eligible for | ||||||
13 | payment under the medical assistance program, and the State | ||||||
14 | shall have no liability for payment of those claims. | ||||||
15 | To the extent consistent with applicable information and | ||||||
16 | privacy, security, and disclosure laws, State and federal | ||||||
17 | agencies and departments shall provide the Illinois Department | ||||||
18 | access to confidential and other information and data | ||||||
19 | necessary to perform eligibility and payment verifications and | ||||||
20 | other Illinois Department functions. This includes, but is not | ||||||
21 | limited to: information pertaining to licensure; | ||||||
22 | certification; earnings; immigration status; citizenship; wage | ||||||
23 | reporting; unearned and earned income; pension income; | ||||||
24 | employment; supplemental security income; social security | ||||||
25 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
26 | National Practitioner Data Bank (NPDB); program and agency |
| |||||||
| |||||||
1 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
2 | corporate information; and death records. | ||||||
3 | The Illinois Department shall enter into agreements with | ||||||
4 | State agencies and departments, and is authorized to enter | ||||||
5 | into agreements with federal agencies and departments, under | ||||||
6 | which such agencies and departments shall share data necessary | ||||||
7 | for medical assistance program integrity functions and | ||||||
8 | oversight. The Illinois Department shall develop, in | ||||||
9 | cooperation with other State departments and agencies, and in | ||||||
10 | compliance with applicable federal laws and regulations, | ||||||
11 | appropriate and effective methods to share such data. At a | ||||||
12 | minimum, and to the extent necessary to provide data sharing, | ||||||
13 | the Illinois Department shall enter into agreements with State | ||||||
14 | agencies and departments, and is authorized to enter into | ||||||
15 | agreements with federal agencies and departments, including , | ||||||
16 | but not limited to: the Secretary of State; the Department of | ||||||
17 | Revenue; the Department of Public Health; the Department of | ||||||
18 | Human Services; and the Department of Financial and | ||||||
19 | Professional Regulation. | ||||||
20 | Beginning in fiscal year 2013, the Illinois Department | ||||||
21 | shall set forth a request for information to identify the | ||||||
22 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
23 | claims system with the goals of streamlining claims processing | ||||||
24 | and provider reimbursement, reducing the number of pending or | ||||||
25 | rejected claims, and helping to ensure a more transparent | ||||||
26 | adjudication process through the utilization of: (i) provider |
| |||||||
| |||||||
1 | data verification and provider screening technology; and (ii) | ||||||
2 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
3 | post-adjudicated predictive modeling with an integrated case | ||||||
4 | management system with link analysis. Such a request for | ||||||
5 | information shall not be considered as a request for proposal | ||||||
6 | or as an obligation on the part of the Illinois Department to | ||||||
7 | take any action or acquire any products or services. | ||||||
8 | The Illinois Department shall establish policies, | ||||||
9 | procedures,
standards and criteria by rule for the | ||||||
10 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
11 | devices and durable medical equipment. Such
rules shall | ||||||
12 | provide, but not be limited to, the following services: (1)
| ||||||
13 | immediate repair or replacement of such devices by recipients; | ||||||
14 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
15 | medical equipment in a cost-effective manner, taking into
| ||||||
16 | consideration the recipient's medical prognosis, the extent of | ||||||
17 | the
recipient's needs, and the requirements and costs for | ||||||
18 | maintaining such
equipment. Subject to prior approval, such | ||||||
19 | rules shall enable a recipient to temporarily acquire and
use | ||||||
20 | alternative or substitute devices or equipment pending repairs | ||||||
21 | or
replacements of any device or equipment previously | ||||||
22 | authorized for such
recipient by the Department. | ||||||
23 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
24 | the Department may, by rule, exempt certain replacement | ||||||
25 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
26 | wheelchair parts, wheelchair accessories, and related seating |
| |||||||
| |||||||
1 | and positioning items, determine the wholesale price by | ||||||
2 | methods other than actual acquisition costs. | ||||||
3 | The Department shall require, by rule, all providers of | ||||||
4 | durable medical equipment to be accredited by an accreditation | ||||||
5 | organization approved by the federal Centers for Medicare and | ||||||
6 | Medicaid Services and recognized by the Department in order to | ||||||
7 | bill the Department for providing durable medical equipment to | ||||||
8 | recipients. No later than 15 months after the effective date | ||||||
9 | of the rule adopted pursuant to this paragraph, all providers | ||||||
10 | must meet the accreditation requirement.
| ||||||
11 | In order to promote environmental responsibility, meet the | ||||||
12 | needs of recipients and enrollees, and achieve significant | ||||||
13 | cost savings, the Department, or a managed care organization | ||||||
14 | under contract with the Department, may provide recipients or | ||||||
15 | managed care enrollees who have a prescription or Certificate | ||||||
16 | of Medical Necessity access to refurbished durable medical | ||||||
17 | equipment under this Section (excluding prosthetic and | ||||||
18 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
19 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
20 | products and associated services) through the State's | ||||||
21 | assistive technology program's reutilization program, using | ||||||
22 | staff with the Assistive Technology Professional (ATP) | ||||||
23 | Certification if the refurbished durable medical equipment: | ||||||
24 | (i) is available; (ii) is less expensive, including shipping | ||||||
25 | costs, than new durable medical equipment of the same type; | ||||||
26 | (iii) is able to withstand at least 3 years of use; (iv) is |
| |||||||
| |||||||
1 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
2 | federal Food and Drug Administration regulations and guidance | ||||||
3 | governing the reprocessing of medical devices in health care | ||||||
4 | settings; and (v) equally meets the needs of the recipient or | ||||||
5 | enrollee. The reutilization program shall confirm that the | ||||||
6 | recipient or enrollee is not already in receipt of same or | ||||||
7 | similar equipment from another service provider, and that the | ||||||
8 | refurbished durable medical equipment equally meets the needs | ||||||
9 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
10 | be construed to limit recipient or enrollee choice to obtain | ||||||
11 | new durable medical equipment or place any additional prior | ||||||
12 | authorization conditions on enrollees of managed care | ||||||
13 | organizations. | ||||||
14 | The Department shall execute, relative to the nursing home | ||||||
15 | prescreening
project, written inter-agency agreements with the | ||||||
16 | Department of Human
Services and the Department on Aging, to | ||||||
17 | effect the following: (i) intake
procedures and common | ||||||
18 | eligibility criteria for those persons who are receiving
| ||||||
19 | non-institutional services; and (ii) the establishment and | ||||||
20 | development of
non-institutional services in areas of the | ||||||
21 | State where they are not currently
available or are | ||||||
22 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
23 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
24 | increase in the determination of need (DON) scores from 29 to | ||||||
25 | 37 for applicants for institutional and home and | ||||||
26 | community-based long term care; if and only if federal |
| |||||||
| |||||||
1 | approval is not granted, the Department may, in conjunction | ||||||
2 | with other affected agencies, implement utilization controls | ||||||
3 | or changes in benefit packages to effectuate a similar savings | ||||||
4 | amount for this population; and (iv) no later than July 1, | ||||||
5 | 2013, minimum level of care eligibility criteria for | ||||||
6 | institutional and home and community-based long term care; and | ||||||
7 | (v) no later than October 1, 2013, establish procedures to | ||||||
8 | permit long term care providers access to eligibility scores | ||||||
9 | for individuals with an admission date who are seeking or | ||||||
10 | receiving services from the long term care provider. In order | ||||||
11 | to select the minimum level of care eligibility criteria, the | ||||||
12 | Governor shall establish a workgroup that includes affected | ||||||
13 | agency representatives and stakeholders representing the | ||||||
14 | institutional and home and community-based long term care | ||||||
15 | interests. This Section shall not restrict the Department from | ||||||
16 | implementing lower level of care eligibility criteria for | ||||||
17 | community-based services in circumstances where federal | ||||||
18 | approval has been granted.
| ||||||
19 | The Illinois Department shall develop and operate, in | ||||||
20 | cooperation
with other State Departments and agencies and in | ||||||
21 | compliance with
applicable federal laws and regulations, | ||||||
22 | appropriate and effective
systems of health care evaluation | ||||||
23 | and programs for monitoring of
utilization of health care | ||||||
24 | services and facilities, as it affects
persons eligible for | ||||||
25 | medical assistance under this Code.
| ||||||
26 | The Illinois Department shall report annually to the |
| |||||||
| |||||||
1 | General Assembly,
no later than the second Friday in April of | ||||||
2 | 1979 and each year
thereafter, in regard to:
| ||||||
3 | (a) actual statistics and trends in utilization of | ||||||
4 | medical services by
public aid recipients;
| ||||||
5 | (b) actual statistics and trends in the provision of | ||||||
6 | the various medical
services by medical vendors;
| ||||||
7 | (c) current rate structures and proposed changes in | ||||||
8 | those rate structures
for the various medical vendors; and
| ||||||
9 | (d) efforts at utilization review and control by the | ||||||
10 | Illinois Department.
| ||||||
11 | The period covered by each report shall be the 3 years | ||||||
12 | ending on the June
30 prior to the report. The report shall | ||||||
13 | include suggested legislation
for consideration by the General | ||||||
14 | Assembly. The requirement for reporting to the General | ||||||
15 | Assembly shall be satisfied
by filing copies of the report as | ||||||
16 | required by Section 3.1 of the General Assembly Organization | ||||||
17 | Act, and filing such additional
copies
with the State | ||||||
18 | Government Report Distribution Center for the General
Assembly | ||||||
19 | as is required under paragraph (t) of Section 7 of the State
| ||||||
20 | Library Act.
| ||||||
21 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
22 | any, is conditioned on the rules being adopted in accordance | ||||||
23 | with all provisions of the Illinois Administrative Procedure | ||||||
24 | Act and all rules and procedures of the Joint Committee on | ||||||
25 | Administrative Rules; any purported rule not so adopted, for | ||||||
26 | whatever reason, is unauthorized. |
| |||||||
| |||||||
1 | On and after July 1, 2012, the Department shall reduce any | ||||||
2 | rate of reimbursement for services or other payments or alter | ||||||
3 | any methodologies authorized by this Code to reduce any rate | ||||||
4 | of reimbursement for services or other payments in accordance | ||||||
5 | with Section 5-5e. | ||||||
6 | Because kidney transplantation can be an appropriate, | ||||||
7 | cost-effective
alternative to renal dialysis when medically | ||||||
8 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
9 | of this Code, beginning October 1, 2014, the Department shall | ||||||
10 | cover kidney transplantation for noncitizens with end-stage | ||||||
11 | renal disease who are not eligible for comprehensive medical | ||||||
12 | benefits, who meet the residency requirements of Section 5-3 | ||||||
13 | of this Code, and who would otherwise meet the financial | ||||||
14 | requirements of the appropriate class of eligible persons | ||||||
15 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
16 | kidney transplantation, such person must be receiving | ||||||
17 | emergency renal dialysis services covered by the Department. | ||||||
18 | Providers under this Section shall be prior approved and | ||||||
19 | certified by the Department to perform kidney transplantation | ||||||
20 | and the services under this Section shall be limited to | ||||||
21 | services associated with kidney transplantation. | ||||||
22 | Notwithstanding any other provision of this Code to the | ||||||
23 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
24 | medication assisted treatment prescribed for the treatment of | ||||||
25 | alcohol dependence or treatment of opioid dependence shall be | ||||||
26 | covered under both fee for service and managed care medical |
| |||||||
| |||||||
1 | assistance programs for persons who are otherwise eligible for | ||||||
2 | medical assistance under this Article and shall not be subject | ||||||
3 | to any (1) utilization control, other than those established | ||||||
4 | under the American Society of Addiction Medicine patient | ||||||
5 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
6 | lifetime restriction limit
mandate. | ||||||
7 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
8 | for the treatment of an opioid overdose, including the | ||||||
9 | medication product, administration devices, and any pharmacy | ||||||
10 | fees or hospital fees related to the dispensing , distribution, | ||||||
11 | and administration of the opioid antagonist, shall be covered | ||||||
12 | under the medical assistance program for persons who are | ||||||
13 | otherwise eligible for medical assistance under this Article. | ||||||
14 | As used in this Section, "opioid antagonist" means a drug that | ||||||
15 | binds to opioid receptors and blocks or inhibits the effect of | ||||||
16 | opioids acting on those receptors, including, but not limited | ||||||
17 | to, naloxone hydrochloride or any other similarly acting drug | ||||||
18 | approved by the U.S. Food and Drug Administration. | ||||||
19 | Upon federal approval, the Department shall provide | ||||||
20 | coverage and reimbursement for all drugs that are approved for | ||||||
21 | marketing by the federal Food and Drug Administration and that | ||||||
22 | are recommended by the federal Public Health Service or the | ||||||
23 | United States Centers for Disease Control and Prevention for | ||||||
24 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
25 | services, including, but not limited to, HIV and sexually | ||||||
26 | transmitted infection screening, treatment for sexually |
| |||||||
| |||||||
1 | transmitted infections, medical monitoring, assorted labs, and | ||||||
2 | counseling to reduce the likelihood of HIV infection among | ||||||
3 | individuals who are not infected with HIV but who are at high | ||||||
4 | risk of HIV infection. | ||||||
5 | A federally qualified health center, as defined in Section | ||||||
6 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
7 | reimbursed by the Department in accordance with the federally | ||||||
8 | qualified health center's encounter rate for services provided | ||||||
9 | to medical assistance recipients that are performed by a | ||||||
10 | dental hygienist, as defined under the Illinois Dental | ||||||
11 | Practice Act, working under the general supervision of a | ||||||
12 | dentist and employed by a federally qualified health center. | ||||||
13 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
14 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
15 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
16 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||||||
17 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | ||||||
18 | 1-1-20; revised 9-18-19.)
| ||||||
19 | (305 ILCS 5/5-41 new) | ||||||
20 | Sec. 5-41. Screening, Brief Intervention, and Referral to | ||||||
21 | Treatment. | ||||||
22 | As used in this Section, "SBIRT" means a comprehensive, | ||||||
23 | integrated, public health approach to the delivery of early | ||||||
24 | intervention and treatment
services for persons who are at | ||||||
25 | risk of developing substance use disorders or have substance |
| |||||||
| |||||||
1 | use disorders including, but not limited to, an addiction to | ||||||
2 | alcohol, opioids,
tobacco, or cannabis.
SBIRT services include | ||||||
3 | all of the following: | ||||||
4 | (1) Screening to quickly assess the severity of | ||||||
5 | substance use and to identify the appropriate level of | ||||||
6 | treatment. | ||||||
7 | (2) Brief intervention focused on increasing insight | ||||||
8 | and awareness regarding substance use and motivation | ||||||
9 | toward behavioral change. | ||||||
10 | (3) Referral to treatment provided to those identified | ||||||
11 | as needing more extensive treatment with access to | ||||||
12 | specialty care. | ||||||
13 | SBIRT services may include, but are not limited to, the | ||||||
14 | following settings and programs: primary care centers, | ||||||
15 | hospital emergency rooms, hospital in-patient units,
trauma | ||||||
16 | centers, community behavioral health programs, and other | ||||||
17 | community settings that provide opportunities for early | ||||||
18 | intervention with at-risk substance users before more severe
| ||||||
19 | consequences occur. | ||||||
20 | The Department of Healthcare and Family Services shall | ||||||
21 | develop and seek federal approval of a SBIRT benefit for which
| ||||||
22 | qualified providers shall be reimbursed under the medical | ||||||
23 | assistance program. | ||||||
24 | In conjunction with the Department of Human Services' | ||||||
25 | Division of Substance Use Prevention and Recovery, the | ||||||
26 | Department of Healthcare and
Family Services may develop a |
| |||||||
| |||||||
1 | methodology and reimbursement rate for SBIRT services provided | ||||||
2 | by qualified providers in approved
settings. | ||||||
3 | For opioid specific SBIRT services provided in a hospital | ||||||
4 | emergency department, the Department of Healthcare and
Family | ||||||
5 | Services shall develop a bundled reimbursement
methodology and | ||||||
6 | rate for a package of opioid treatment services, which include | ||||||
7 | initiation of medication for the treatment of opioid use | ||||||
8 | disorder in
the emergency department setting, including | ||||||
9 | assessment, referral to ongoing care, and arranging access to | ||||||
10 | supportive services when necessary. This
package of opioid | ||||||
11 | related services shall be billed on a separate claim and shall | ||||||
12 | be reimbursed outside of the Enhanced Ambulatory Patient
| ||||||
13 | Grouping system. ".
|