|
| | 100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4114 Introduced , by Rep. Peter Breen SYNOPSIS AS INTRODUCED:
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Creates the No Taxpayer Funding for Abortion Act. Provides that neither the State nor any of its subdivisions may authorize the use of, appropriate, or expend funds to pay for an abortion or to cover any part of the costs of a health plan that includes coverage of abortion or to provide or refer for an abortion, unless a woman who suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death if an abortion is not performed. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code. Excludes from the programs of health benefits and services authorized under those Acts coverage for elective abortions as provided in the No Taxpayer Funding for Abortion Act. Prohibits a physician who has been found guilty of performing an abortion
procedure in a willful and wanton manner upon a woman who was
not pregnant when the abortion procedure was performed from participating in the State's Medical Assistance Program. Provides that the Department of Healthcare and Family Services shall require a written statement, including the required opinion
of a physician, to accompany a claim for reimbursement for
abortions or induced miscarriages or premature births. Makes other changes. Amends the Problem Pregnancy Health Services and Care
Act. Permits the Department of Human Services to make grants to nonprofit
agencies and organizations that do not use those grants to
refer or counsel for, or perform, abortions. Contains provisions regarding applicability and preempts home rule. Effective on the earlier of the effective date of Public Act 100-538 or June 1, 2018.
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| | | FISCAL NOTE ACT MAY APPLY | | HOME RULE NOTE ACT MAY APPLY |
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| 1 | | AN ACT concerning abortion.
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| 2 | | Be it enacted by the People of the State of Illinois,
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| 3 | | represented in the General Assembly:
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| 4 | | Section 1. Short title. This Act may be cited as the No |
| 5 | | Taxpayer Funding for Abortion Act.
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| 6 | | Section 5. Public policy. It is the public policy of this |
| 7 | | State that the General Assembly of the State of Illinois does |
| 8 | | solemnly declare and find in reaffirmation of the longstanding |
| 9 | | policy of this State that the unborn child is a human being |
| 10 | | from the time of conception and has a right to life and, to the |
| 11 | | extent consistent with the United States Constitution, |
| 12 | | Illinois law should be interpreted to recognize that right to |
| 13 | | life and to protect unborn life. |
| 14 | | The General Assembly further declares and finds that, while |
| 15 | | the people of Illinois hold a variety of positions on the issue |
| 16 | | of abortion, they generally oppose the use of tax dollars to |
| 17 | | pay for elective abortions and support the federal Hyde |
| 18 | | Amendment, named after the late Henry J. Hyde, whose memory is |
| 19 | | revered and service celebrated as a Congressman from the great |
| 20 | | State of Illinois. This Act honors the strong beliefs of the |
| 21 | | people of Illinois by prohibiting the taxpayer funding of |
| 22 | | abortion in this State.
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| 1 | | Section 10. Use of funds to pay for abortions prohibited; |
| 2 | | exceptions. Notwithstanding any other provision of law, |
| 3 | | neither the State nor any of its subdivisions may authorize the |
| 4 | | use of, appropriate, or expend any funds to pay for any |
| 5 | | abortion or to cover any part of the costs of any health plan |
| 6 | | that includes coverage of abortion or to provide or refer for |
| 7 | | any abortion, except in the case where a woman suffers from a |
| 8 | | physical disorder, physical injury, or physical illness that |
| 9 | | would, as certified by a physician, place the woman in danger |
| 10 | | of death unless an abortion is performed, including a |
| 11 | | life-endangering physical condition caused by or arising from |
| 12 | | the pregnancy itself, or in such other circumstances as |
| 13 | | required by federal law.
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| 14 | | Section 900. The State Employees Group Insurance Act of |
| 15 | | 1971 is amended by changing Sections 6 and 6.1 as follows:
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| 16 | | (5 ILCS 375/6) (from Ch. 127, par. 526)
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| 17 | | (Text of Section before amendment by P.A. 100-538)
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| 18 | | Sec. 6. Program of health benefits.
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| 19 | | (a) The program of health benefits shall provide for |
| 20 | | protection
against the financial costs of health care expenses |
| 21 | | incurred in and out
of hospital including basic |
| 22 | | hospital-surgical-medical coverages. The program
may include, |
| 23 | | but shall not be limited to, such supplemental coverages as
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| 24 | | out-patient diagnostic X-ray and laboratory expenses, |
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| 1 | | prescription drugs,
dental services, hearing evaluations, |
| 2 | | hearing aids, the dispensing and
fitting
of hearing aids, and |
| 3 | | similar group benefits
as are now or may become available. |
| 4 | | However, nothing in this Act shall
be construed to permit, on |
| 5 | | or after July 1, 1980, the non-contributory portion
of any such |
| 6 | | program to include the expenses of obtaining an abortion, |
| 7 | | induced
miscarriage or induced premature birth unless, in the |
| 8 | | opinion of a physician,
such procedures are necessary for the |
| 9 | | preservation of the life of the woman
seeking such treatment, |
| 10 | | or except an induced premature birth intended to
produce a live |
| 11 | | viable child and such procedure is necessary for the health
of |
| 12 | | the mother or the unborn child. The program may also include
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| 13 | | coverage for those who rely on treatment by prayer or spiritual |
| 14 | | means
alone for healing in accordance with the tenets and |
| 15 | | practice of a
recognized religious denomination.
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| 16 | | The program of health benefits shall be designed by the |
| 17 | | Director
(1) to provide a reasonable relationship between the |
| 18 | | benefits to be
included and the expected distribution of |
| 19 | | expenses of each such type to
be incurred by the covered |
| 20 | | members and dependents,
(2) to specify, as covered benefits and |
| 21 | | as optional benefits, the
medical services of practitioners in |
| 22 | | all categories licensed under the
Medical Practice Act of 1987, |
| 23 | | (3) to include
reasonable controls, which may include |
| 24 | | deductible and co-insurance
provisions, applicable to some or |
| 25 | | all of the benefits, or a coordination
of benefits provision, |
| 26 | | to prevent or minimize unnecessary utilization of
the various |
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| 1 | | hospital, surgical and medical expenses to be provided and
to |
| 2 | | provide reasonable assurance of stability of the program, and |
| 3 | | (4) to
provide benefits to the extent possible to members |
| 4 | | throughout the
State, wherever located, on an equitable basis.
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| 5 | | Notwithstanding any other provision of this Section or Act,
for |
| 6 | | all members or dependents who are eligible for benefits under |
| 7 | | Social
Security or the
Railroad Retirement system or who had |
| 8 | | sufficient Medicare-covered government
employment,
the
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| 9 | | Department shall reduce benefits
which would otherwise be paid |
| 10 | | by Medicare, by the amount of benefits for
which the member or |
| 11 | | dependents are eligible
under Medicare, except that such |
| 12 | | reduction in benefits shall apply only to
those members or |
| 13 | | dependents who (1) first become
eligible for such medicare |
| 14 | | coverage on or after the effective date of this
amendatory Act |
| 15 | | of 1992; or (2) are Medicare-eligible members or dependents of
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| 16 | | a local government unit which began participation in the |
| 17 | | program on or after
July 1, 1992; or (3) remain eligible for |
| 18 | | but no longer receive
Medicare coverage which they had been |
| 19 | | receiving on or after the effective date
of this amendatory Act |
| 20 | | of 1992.
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| 21 | | Notwithstanding any other provisions of this Act, where a |
| 22 | | covered member or
dependents are eligible for benefits under |
| 23 | | the federal Medicare health
insurance program (Title XVIII of |
| 24 | | the Social Security Act as added by
Public Law 89-97, 89th |
| 25 | | Congress), benefits paid under the State of Illinois
program or |
| 26 | | plan will be reduced by the amount of benefits paid by |
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| 1 | | Medicare.
For members or dependents
who are eligible for |
| 2 | | benefits under Social Security
or the Railroad Retirement |
| 3 | | system or who had sufficient Medicare-covered
government |
| 4 | | employment, benefits shall be reduced by the amount for which
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| 5 | | the member or dependent is eligible under Medicare,
except that |
| 6 | | such reduction in benefits shall apply only to those
members or |
| 7 | | dependents who (1) first become eligible for such
Medicare |
| 8 | | coverage on or after the effective date of this amendatory Act
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| 9 | | of 1992; or (2) are Medicare-eligible members or dependents of |
| 10 | | a local
government unit which began participation in the |
| 11 | | program on or after July 1,
1992; or (3) remain eligible for, |
| 12 | | but no longer receive Medicare
coverage which they had been |
| 13 | | receiving on or after the effective date of this
amendatory Act |
| 14 | | of 1992. Premiums may be adjusted, where applicable, to an
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| 15 | | amount deemed by the Director to be reasonably consistent with |
| 16 | | any reduction
of benefits.
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| 17 | | (b) A member, not otherwise covered by this Act, who has |
| 18 | | retired as a
participating member under Article 2 of the |
| 19 | | Illinois Pension Code
but is ineligible for the retirement |
| 20 | | annuity under Section 2-119 of the
Illinois
Pension Code, shall |
| 21 | | pay the premiums for coverage, not
exceeding the amount paid by |
| 22 | | the State for the non-contributory coverage for
other members, |
| 23 | | under the group health benefits program under this Act. The
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| 24 | | Director shall determine the premiums to be paid
by a member |
| 25 | | under this subsection (b).
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| 26 | | (Source: P.A. 93-47, eff. 7-1-03.)
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| 1 | | (Text of Section after amendment by P.A. 100-538)
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| 2 | | Sec. 6. Program of health benefits.
|
| 3 | | (a) The program of health benefits shall provide for |
| 4 | | protection
against the financial costs of health care expenses |
| 5 | | incurred in and out
of hospital including basic |
| 6 | | hospital-surgical-medical coverages. The program
may include, |
| 7 | | but shall not be limited to, such supplemental coverages as
|
| 8 | | out-patient diagnostic X-ray and laboratory expenses, |
| 9 | | prescription drugs,
dental services, hearing evaluations, |
| 10 | | hearing aids, the dispensing and
fitting
of hearing aids, and |
| 11 | | similar group benefits
as are now or may become available, |
| 12 | | except as provided in the No Taxpayer Funding for Abortion Act. |
| 13 | | The program may also include
coverage for those who rely on |
| 14 | | treatment by prayer or spiritual means
alone for healing in |
| 15 | | accordance with the tenets and practice of a
recognized |
| 16 | | religious denomination.
|
| 17 | | The program of health benefits shall be designed by the |
| 18 | | Director
(1) to provide a reasonable relationship between the |
| 19 | | benefits to be
included and the expected distribution of |
| 20 | | expenses of each such type to
be incurred by the covered |
| 21 | | members and dependents,
(2) to specify, as covered benefits and |
| 22 | | as optional benefits, the
medical services of practitioners in |
| 23 | | all categories licensed under the
Medical Practice Act of 1987, |
| 24 | | (3) to include
reasonable controls, which may include |
| 25 | | deductible and co-insurance
provisions, applicable to some or |
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| 1 | | all of the benefits, or a coordination
of benefits provision, |
| 2 | | to prevent or minimize unnecessary utilization of
the various |
| 3 | | hospital, surgical and medical expenses to be provided and
to |
| 4 | | provide reasonable assurance of stability of the program, and |
| 5 | | (4) to
provide benefits to the extent possible to members |
| 6 | | throughout the
State, wherever located, on an equitable basis.
|
| 7 | | Notwithstanding any other provision of this Section or Act,
for |
| 8 | | all members or dependents who are eligible for benefits under |
| 9 | | Social
Security or the
Railroad Retirement system or who had |
| 10 | | sufficient Medicare-covered government
employment,
the
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| 11 | | Department shall reduce benefits
which would otherwise be paid |
| 12 | | by Medicare, by the amount of benefits for
which the member or |
| 13 | | dependents are eligible
under Medicare, except that such |
| 14 | | reduction in benefits shall apply only to
those members or |
| 15 | | dependents who (1) first become
eligible for such medicare |
| 16 | | coverage on or after the effective date of this
amendatory Act |
| 17 | | of 1992; or (2) are Medicare-eligible members or dependents of
|
| 18 | | a local government unit which began participation in the |
| 19 | | program on or after
July 1, 1992; or (3) remain eligible for |
| 20 | | but no longer receive
Medicare coverage which they had been |
| 21 | | receiving on or after the effective date
of this amendatory Act |
| 22 | | of 1992.
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| 23 | | Notwithstanding any other provisions of this Act, where a |
| 24 | | covered member or
dependents are eligible for benefits under |
| 25 | | the federal Medicare health
insurance program (Title XVIII of |
| 26 | | the Social Security Act as added by
Public Law 89-97, 89th |
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| 1 | | Congress), benefits paid under the State of Illinois
program or |
| 2 | | plan will be reduced by the amount of benefits paid by |
| 3 | | Medicare.
For members or dependents
who are eligible for |
| 4 | | benefits under Social Security
or the Railroad Retirement |
| 5 | | system or who had sufficient Medicare-covered
government |
| 6 | | employment, benefits shall be reduced by the amount for which
|
| 7 | | the member or dependent is eligible under Medicare,
except that |
| 8 | | such reduction in benefits shall apply only to those
members or |
| 9 | | dependents who (1) first become eligible for such
Medicare |
| 10 | | coverage on or after the effective date of this amendatory Act
|
| 11 | | of 1992; or (2) are Medicare-eligible members or dependents of |
| 12 | | a local
government unit which began participation in the |
| 13 | | program on or after July 1,
1992; or (3) remain eligible for, |
| 14 | | but no longer receive Medicare
coverage which they had been |
| 15 | | receiving on or after the effective date of this
amendatory Act |
| 16 | | of 1992. Premiums may be adjusted, where applicable, to an
|
| 17 | | amount deemed by the Director to be reasonably consistent with |
| 18 | | any reduction
of benefits.
|
| 19 | | (b) A member, not otherwise covered by this Act, who has |
| 20 | | retired as a
participating member under Article 2 of the |
| 21 | | Illinois Pension Code
but is ineligible for the retirement |
| 22 | | annuity under Section 2-119 of the
Illinois
Pension Code, shall |
| 23 | | pay the premiums for coverage, not
exceeding the amount paid by |
| 24 | | the State for the non-contributory coverage for
other members, |
| 25 | | under the group health benefits program under this Act. The
|
| 26 | | Director shall determine the premiums to be paid
by a member |
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| 1 | | under this subsection (b).
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| 2 | | (Source: P.A. 100-538, eff. 1-1-18.)
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| 3 | | (5 ILCS 375/6.1) (from Ch. 127, par. 526.1)
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| 4 | | (Text of Section before amendment by P.A. 100-538)
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| 5 | | Sec. 6.1.
The program of health benefits may offer as an |
| 6 | | alternative,
available on an optional basis, coverage through
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| 7 | | health maintenance organizations. That part of the premium for
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| 8 | | such coverage which is in excess of the amount which would
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| 9 | | otherwise be paid by the State for the program of health |
| 10 | | benefits shall
be paid by the member who elects such |
| 11 | | alternative coverage and shall
be collected as provided for |
| 12 | | premiums for other optional coverages.
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| 13 | | However, nothing in this Act shall be construed to permit, |
| 14 | | after
the effective date of this amendatory Act of 1983, the |
| 15 | | noncontributory portion
of any such program to include the |
| 16 | | expenses of obtaining an abortion, induced
miscarriage or |
| 17 | | induced premature birth unless, in the opinion of a physician,
|
| 18 | | such procedures are necessary for the preservation of the life |
| 19 | | of the woman
seeking such treatment, or except an induced |
| 20 | | premature birth intended to
produce a live viable child and |
| 21 | | such procedure is necessary for the health
of the mother or her |
| 22 | | unborn child.
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| 23 | | (Source: P.A. 85-848.)
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| 24 | | (Text of Section after amendment by P.A. 100-538)
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| 1 | | Sec. 6.1.
The program of health benefits may offer as an |
| 2 | | alternative,
available on an optional basis, coverage through
|
| 3 | | health maintenance organizations. That part of the premium for
|
| 4 | | such coverage which is in excess of the amount which would
|
| 5 | | otherwise be paid by the State for the program of health |
| 6 | | benefits shall
be paid by the member who elects such |
| 7 | | alternative coverage and shall
be collected as provided for |
| 8 | | premiums for other optional coverages, except as provided in |
| 9 | | the No Taxpayer Funding for Abortion Act.
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| 10 | | (Source: P.A. 100-538, eff. 1-1-18.)
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| 11 | | Section 905. The Illinois Public Aid Code is amended by |
| 12 | | changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
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| 13 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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| 14 | | (Text of Section before amendment by P.A. 100-538) |
| 15 | | Sec. 5-5. Medical services. The Illinois Department, by |
| 16 | | rule, shall
determine the quantity and quality of and the rate |
| 17 | | of reimbursement for the
medical assistance for which
payment |
| 18 | | will be authorized, and the medical services to be provided,
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| 19 | | which may include all or part of the following: (1) inpatient |
| 20 | | hospital
services; (2) outpatient hospital services; (3) other |
| 21 | | laboratory and
X-ray services; (4) skilled nursing home |
| 22 | | services; (5) physicians'
services whether furnished in the |
| 23 | | office, the patient's home, a
hospital, a skilled nursing home, |
| 24 | | or elsewhere; (6) medical care, or any
other type of remedial |
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| 1 | | care furnished by licensed practitioners; (7)
home health care |
| 2 | | services; (8) private duty nursing service; (9) clinic
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| 3 | | services; (10) dental services, including prevention and |
| 4 | | treatment of periodontal disease and dental caries disease for |
| 5 | | pregnant women, provided by an individual licensed to practice |
| 6 | | dentistry or dental surgery; for purposes of this item (10), |
| 7 | | "dental services" means diagnostic, preventive, or corrective |
| 8 | | procedures provided by or under the supervision of a dentist in |
| 9 | | the practice of his or her profession; (11) physical therapy |
| 10 | | and related
services; (12) prescribed drugs, dentures, and |
| 11 | | prosthetic devices; and
eyeglasses prescribed by a physician |
| 12 | | skilled in the diseases of the eye,
or by an optometrist, |
| 13 | | whichever the person may select; (13) other
diagnostic, |
| 14 | | screening, preventive, and rehabilitative services, including |
| 15 | | to ensure that the individual's need for intervention or |
| 16 | | treatment of mental disorders or substance use disorders or |
| 17 | | co-occurring mental health and substance use disorders is |
| 18 | | determined using a uniform screening, assessment, and |
| 19 | | evaluation process inclusive of criteria, for children and |
| 20 | | adults; for purposes of this item (13), a uniform screening, |
| 21 | | assessment, and evaluation process refers to a process that |
| 22 | | includes an appropriate evaluation and, as warranted, a |
| 23 | | referral; "uniform" does not mean the use of a singular |
| 24 | | instrument, tool, or process that all must utilize; (14)
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| 25 | | transportation and such other expenses as may be necessary; |
| 26 | | (15) medical
treatment of sexual assault survivors, as defined |
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| 1 | | in
Section 1a of the Sexual Assault Survivors Emergency |
| 2 | | Treatment Act, for
injuries sustained as a result of the sexual |
| 3 | | assault, including
examinations and laboratory tests to |
| 4 | | discover evidence which may be used in
criminal proceedings |
| 5 | | arising from the sexual assault; (16) the
diagnosis and |
| 6 | | treatment of sickle cell anemia; and (17)
any other medical |
| 7 | | care, and any other type of remedial care recognized
under the |
| 8 | | laws of this State, but not including abortions, or induced
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| 9 | | miscarriages or premature births, unless, in the opinion of a |
| 10 | | physician,
such procedures are necessary for the preservation |
| 11 | | of the life of the
woman seeking such treatment, or except an |
| 12 | | induced premature birth
intended to produce a live viable child |
| 13 | | and such procedure is necessary
for the health of the mother or |
| 14 | | her unborn child. The Illinois Department,
by rule, shall |
| 15 | | prohibit any physician from providing medical assistance
to |
| 16 | | anyone eligible therefor under this Code where such physician |
| 17 | | has been
found guilty of performing an abortion procedure in a |
| 18 | | wilful and wanton
manner upon a woman who was not pregnant at |
| 19 | | the time such abortion
procedure was performed. The term "any |
| 20 | | other type of remedial care" shall
include nursing care and |
| 21 | | nursing home service for persons who rely on
treatment by |
| 22 | | spiritual means alone through prayer for healing.
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| 23 | | Notwithstanding any other provision of this Section, a |
| 24 | | comprehensive
tobacco use cessation program that includes |
| 25 | | purchasing prescription drugs or
prescription medical devices |
| 26 | | approved by the Food and Drug Administration shall
be covered |
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| 1 | | under the medical assistance
program under this Article for |
| 2 | | persons who are otherwise eligible for
assistance under this |
| 3 | | Article.
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| 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 under |
| 20 | | 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 |
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| 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 and |
| 4 | | Family Services may provide the following services to
persons
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| 5 | | 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
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| 11 | | (2) eyeglasses prescribed by a physician skilled in the |
| 12 | | diseases of the
eye, or by an optometrist, whichever the |
| 13 | | person may select.
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| 14 | | Notwithstanding any other provision of this Code and |
| 15 | | subject to federal approval, the Department may adopt rules to |
| 16 | | allow a dentist who is volunteering his or her service at no |
| 17 | | cost to render dental services through an enrolled |
| 18 | | not-for-profit health clinic without the dentist personally |
| 19 | | enrolling as a participating provider in the medical assistance |
| 20 | | program. A not-for-profit health clinic shall include a public |
| 21 | | health clinic or Federally Qualified Health Center or other |
| 22 | | enrolled provider, as determined by the Department, through |
| 23 | | which dental services covered under this Section are performed. |
| 24 | | The Department shall establish a process for payment of claims |
| 25 | | for reimbursement for covered dental services rendered under |
| 26 | | this provision. |
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| 1 | | The Illinois Department, by rule, may distinguish and |
| 2 | | classify the
medical services to be provided only in accordance |
| 3 | | with the classes of
persons designated in Section 5-2.
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| 4 | | The Department of Healthcare and Family Services must |
| 5 | | provide coverage and reimbursement for amino acid-based |
| 6 | | elemental formulas, regardless of delivery method, for the |
| 7 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
| 8 | | short bowel syndrome when the prescribing physician has issued |
| 9 | | a written order stating that the amino acid-based elemental |
| 10 | | formula is medically necessary.
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| 11 | | The Illinois Department shall authorize the provision of, |
| 12 | | and shall
authorize payment for, screening by low-dose |
| 13 | | mammography for the presence of
occult breast cancer for women |
| 14 | | 35 years of age or older who are eligible
for medical |
| 15 | | assistance under this Article, as follows: |
| 16 | | (A) A baseline
mammogram for women 35 to 39 years of |
| 17 | | age.
|
| 18 | | (B) An annual mammogram for women 40 years of age or |
| 19 | | older. |
| 20 | | (C) A mammogram at the age and intervals considered |
| 21 | | medically necessary by the woman's health care provider for |
| 22 | | women under 40 years of age and having a family history of |
| 23 | | breast cancer, prior personal history of breast cancer, |
| 24 | | positive genetic testing, or other risk factors. |
| 25 | | (D) A comprehensive ultrasound screening of an entire |
| 26 | | breast or breasts if a mammogram demonstrates |
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| 1 | | heterogeneous or dense breast tissue, when medically |
| 2 | | necessary as determined by a physician licensed to practice |
| 3 | | medicine in all of its branches. |
| 4 | | (E) A screening MRI when medically necessary, as |
| 5 | | determined by a physician licensed to practice medicine in |
| 6 | | all of its branches. |
| 7 | | All screenings
shall
include a physical breast exam, |
| 8 | | instruction on self-examination and
information regarding the |
| 9 | | frequency of self-examination and its value as a
preventative |
| 10 | | tool. For purposes of this Section, "low-dose mammography" |
| 11 | | means
the x-ray examination of the breast using equipment |
| 12 | | dedicated specifically
for mammography, including the x-ray |
| 13 | | tube, filter, compression device,
and image receptor, with an |
| 14 | | average radiation exposure delivery
of less than one rad per |
| 15 | | breast for 2 views of an average size breast.
The term also |
| 16 | | includes digital mammography and includes breast |
| 17 | | tomosynthesis. As used in this Section, the term "breast |
| 18 | | tomosynthesis" means a radiologic procedure that involves the |
| 19 | | acquisition of projection images over the stationary breast to |
| 20 | | produce cross-sectional digital three-dimensional images of |
| 21 | | the breast. If, at any time, the Secretary of the United States |
| 22 | | Department of Health and Human Services, or its successor |
| 23 | | agency, promulgates rules or regulations to be published in the |
| 24 | | Federal Register or publishes a comment in the Federal Register |
| 25 | | or issues an opinion, guidance, or other action that would |
| 26 | | require the State, pursuant to any provision of the Patient |
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| 1 | | Protection and Affordable Care Act (Public Law 111-148), |
| 2 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any |
| 3 | | successor provision, to defray the cost of any coverage for |
| 4 | | breast tomosynthesis outlined in this paragraph, then the |
| 5 | | requirement that an insurer cover breast tomosynthesis is |
| 6 | | inoperative other than any such coverage authorized under |
| 7 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and |
| 8 | | the State shall not assume any obligation for the cost of |
| 9 | | coverage for breast tomosynthesis set forth in this paragraph.
|
| 10 | | On and after January 1, 2016, the Department shall ensure |
| 11 | | that all networks of care for adult clients of the Department |
| 12 | | include access to at least one breast imaging Center of Imaging |
| 13 | | Excellence as certified by the American College of Radiology. |
| 14 | | On and after January 1, 2012, providers participating in a |
| 15 | | quality improvement program approved by the Department shall be |
| 16 | | reimbursed for screening and diagnostic mammography at the same |
| 17 | | rate as the Medicare program's rates, including the increased |
| 18 | | reimbursement for digital mammography. |
| 19 | | The Department shall convene an expert panel including |
| 20 | | representatives of hospitals, free-standing mammography |
| 21 | | facilities, and doctors, including radiologists, to establish |
| 22 | | quality standards for mammography. |
| 23 | | On and after January 1, 2017, providers participating in a |
| 24 | | breast cancer treatment quality improvement program approved |
| 25 | | by the Department shall be reimbursed for breast cancer |
| 26 | | treatment at a rate that is no lower than 95% of the Medicare |
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| 1 | | program's rates for the data elements included in the breast |
| 2 | | cancer treatment quality program. |
| 3 | | The Department shall convene an expert panel, including |
| 4 | | representatives of hospitals, free standing breast cancer |
| 5 | | treatment centers, breast cancer quality organizations, and |
| 6 | | doctors, including breast surgeons, reconstructive breast |
| 7 | | surgeons, oncologists, and primary care providers to establish |
| 8 | | quality standards for breast cancer treatment. |
| 9 | | Subject to federal approval, the Department shall |
| 10 | | establish a rate methodology for mammography at federally |
| 11 | | qualified health centers and other encounter-rate clinics. |
| 12 | | These clinics or centers may also collaborate with other |
| 13 | | hospital-based mammography facilities. By January 1, 2016, the |
| 14 | | Department shall report to the General Assembly on the status |
| 15 | | of the provision set forth in this paragraph. |
| 16 | | The Department shall establish a methodology to remind |
| 17 | | women who are age-appropriate for screening mammography, but |
| 18 | | who have not received a mammogram within the previous 18 |
| 19 | | months, of the importance and benefit of screening mammography. |
| 20 | | The Department shall work with experts in breast cancer |
| 21 | | outreach and patient navigation to optimize these reminders and |
| 22 | | shall establish a methodology for evaluating their |
| 23 | | effectiveness and modifying the methodology based on the |
| 24 | | evaluation. |
| 25 | | The Department shall establish a performance goal for |
| 26 | | primary care providers with respect to their female patients |
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| 1 | | over age 40 receiving an annual mammogram. This performance |
| 2 | | goal shall be used to provide additional reimbursement in the |
| 3 | | form of a quality performance bonus to primary care providers |
| 4 | | who meet that goal. |
| 5 | | The Department shall devise a means of case-managing or |
| 6 | | patient navigation for beneficiaries diagnosed with breast |
| 7 | | cancer. This program shall initially operate as a pilot program |
| 8 | | in areas of the State with the highest incidence of mortality |
| 9 | | related to breast cancer. At least one pilot program site shall |
| 10 | | be in the metropolitan Chicago area and at least one site shall |
| 11 | | be outside the metropolitan Chicago area. On or after July 1, |
| 12 | | 2016, the pilot program shall be expanded to include one site |
| 13 | | in western Illinois, one site in southern Illinois, one site in |
| 14 | | central Illinois, and 4 sites within metropolitan Chicago. An |
| 15 | | evaluation of the pilot program shall be carried out measuring |
| 16 | | health outcomes and cost of care for those served by the pilot |
| 17 | | program compared to similarly situated patients who are not |
| 18 | | served by the pilot program. |
| 19 | | The Department shall require all networks of care to |
| 20 | | develop a means either internally or by contract with experts |
| 21 | | in navigation and community outreach to navigate cancer |
| 22 | | patients to comprehensive care in a timely fashion. The |
| 23 | | Department shall require all networks of care to include access |
| 24 | | for patients diagnosed with cancer to at least one academic |
| 25 | | commission on cancer-accredited cancer program as an |
| 26 | | in-network covered benefit. |
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| 1 | | Any medical or health care provider shall immediately |
| 2 | | recommend, to
any pregnant woman who is being provided prenatal |
| 3 | | services and is suspected
of drug abuse or is addicted as |
| 4 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
| 5 | | Act, referral to a local substance abuse treatment provider
|
| 6 | | licensed by the Department of Human Services or to a licensed
|
| 7 | | hospital which provides substance abuse treatment services. |
| 8 | | The Department of Healthcare and Family Services
shall assure |
| 9 | | coverage for the cost of treatment of the drug abuse or
|
| 10 | | addiction for pregnant recipients in accordance with the |
| 11 | | Illinois Medicaid
Program in conjunction with the Department of |
| 12 | | Human Services.
|
| 13 | | All medical providers providing medical assistance to |
| 14 | | pregnant women
under this Code shall receive information from |
| 15 | | the Department on the
availability of services under the Drug |
| 16 | | Free Families with a Future or any
comparable program providing |
| 17 | | case management services for addicted women,
including |
| 18 | | information on appropriate referrals for other social services
|
| 19 | | that may be needed by addicted women in addition to treatment |
| 20 | | for addiction.
|
| 21 | | The Illinois Department, in cooperation with the |
| 22 | | Departments of Human
Services (as successor to the Department |
| 23 | | of Alcoholism and Substance
Abuse) and Public Health, through a |
| 24 | | public awareness campaign, may
provide information concerning |
| 25 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
| 26 | | health care, and other pertinent programs directed at
reducing |
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| 1 | | the number of drug-affected infants born to recipients of |
| 2 | | medical
assistance.
|
| 3 | | Neither the Department of Healthcare and Family Services |
| 4 | | nor the Department of Human
Services shall sanction the |
| 5 | | recipient solely on the basis of
her substance abuse.
|
| 6 | | The Illinois Department shall establish such regulations |
| 7 | | governing
the dispensing of health services under this Article |
| 8 | | as it shall deem
appropriate. The Department
should
seek the |
| 9 | | advice of formal professional advisory committees appointed by
|
| 10 | | the Director of the Illinois Department for the purpose of |
| 11 | | providing regular
advice on policy and administrative matters, |
| 12 | | information dissemination and
educational activities for |
| 13 | | medical and health care providers, and
consistency in |
| 14 | | procedures to the Illinois Department.
|
| 15 | | The Illinois Department may develop and contract with |
| 16 | | Partnerships of
medical providers to arrange medical services |
| 17 | | for persons eligible under
Section 5-2 of this Code. |
| 18 | | Implementation of this Section may be by
demonstration projects |
| 19 | | in certain geographic areas. The Partnership shall
be |
| 20 | | represented by a sponsor organization. The Department, by rule, |
| 21 | | shall
develop qualifications for sponsors of Partnerships. |
| 22 | | Nothing in this
Section shall be construed to require that the |
| 23 | | sponsor organization be a
medical organization.
|
| 24 | | The sponsor must negotiate formal written contracts with |
| 25 | | medical
providers for physician services, inpatient and |
| 26 | | outpatient hospital care,
home health services, treatment for |
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| 1 | | alcoholism and substance abuse, and
other services determined |
| 2 | | necessary by the Illinois Department by rule for
delivery by |
| 3 | | Partnerships. Physician services must include prenatal and
|
| 4 | | obstetrical care. The Illinois Department shall reimburse |
| 5 | | medical services
delivered by Partnership providers to clients |
| 6 | | in target areas according to
provisions of this Article and the |
| 7 | | Illinois Health Finance Reform Act,
except that:
|
| 8 | | (1) Physicians participating in a Partnership and |
| 9 | | providing certain
services, which shall be determined by |
| 10 | | the Illinois Department, to persons
in areas covered by the |
| 11 | | Partnership may receive an additional surcharge
for such |
| 12 | | services.
|
| 13 | | (2) The Department may elect to consider and negotiate |
| 14 | | financial
incentives to encourage the development of |
| 15 | | Partnerships and the efficient
delivery of medical care.
|
| 16 | | (3) Persons receiving medical services through |
| 17 | | Partnerships may receive
medical and case management |
| 18 | | services above the level usually offered
through the |
| 19 | | medical assistance program.
|
| 20 | | Medical providers shall be required to meet certain |
| 21 | | qualifications to
participate in Partnerships to ensure the |
| 22 | | delivery of high quality medical
services. These |
| 23 | | qualifications shall be determined by rule of the Illinois
|
| 24 | | Department and may be higher than qualifications for |
| 25 | | participation in the
medical assistance program. Partnership |
| 26 | | sponsors may prescribe reasonable
additional qualifications |
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| 1 | | for participation by medical providers, only with
the prior |
| 2 | | written approval of the Illinois Department.
|
| 3 | | Nothing in this Section shall limit the free choice of |
| 4 | | practitioners,
hospitals, and other providers of medical |
| 5 | | services by clients.
In order to ensure patient freedom of |
| 6 | | choice, the Illinois Department shall
immediately promulgate |
| 7 | | all rules and take all other necessary actions so that
provided |
| 8 | | services may be accessed from therapeutically certified |
| 9 | | optometrists
to the full extent of the Illinois Optometric |
| 10 | | Practice Act of 1987 without
discriminating between service |
| 11 | | providers.
|
| 12 | | The Department shall apply for a waiver from the United |
| 13 | | States Health
Care Financing Administration to allow for the |
| 14 | | implementation of
Partnerships under this Section.
|
| 15 | | The Illinois Department shall require health care |
| 16 | | providers to maintain
records that document the medical care |
| 17 | | and services provided to recipients
of Medical Assistance under |
| 18 | | this Article. Such records must be retained for a period of not |
| 19 | | less than 6 years from the date of service or as provided by |
| 20 | | applicable State law, whichever period is longer, except that |
| 21 | | if an audit is initiated within the required retention period |
| 22 | | then the records must be retained until the audit is completed |
| 23 | | and every exception is resolved. The Illinois Department shall
|
| 24 | | require health care providers to make available, when |
| 25 | | authorized by the
patient, in writing, the medical records in a |
| 26 | | timely fashion to other
health care providers who are treating |
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| 1 | | or serving persons eligible for
Medical Assistance under this |
| 2 | | Article. All dispensers of medical services
shall be required |
| 3 | | to maintain and retain business and professional records
|
| 4 | | sufficient to fully and accurately document the nature, scope, |
| 5 | | details and
receipt of the health care provided to persons |
| 6 | | eligible for medical
assistance under this Code, in accordance |
| 7 | | with regulations promulgated by
the Illinois Department. The |
| 8 | | rules and regulations shall require that proof
of the receipt |
| 9 | | of prescription drugs, dentures, prosthetic devices and
|
| 10 | | eyeglasses by eligible persons under this Section accompany |
| 11 | | each claim
for reimbursement submitted by the dispenser of such |
| 12 | | medical services.
No such claims for reimbursement shall be |
| 13 | | approved for payment by the Illinois
Department without such |
| 14 | | proof of receipt, unless the Illinois Department
shall have put |
| 15 | | into effect and shall be operating a system of post-payment
|
| 16 | | audit and review which shall, on a sampling basis, be deemed |
| 17 | | adequate by
the Illinois Department to assure that such drugs, |
| 18 | | dentures, prosthetic
devices and eyeglasses for which payment |
| 19 | | is being made are actually being
received by eligible |
| 20 | | recipients. Within 90 days after September 16, 1984 (the |
| 21 | | effective date of Public Act 83-1439), the Illinois Department |
| 22 | | shall establish a
current list of acquisition costs for all |
| 23 | | prosthetic devices and any
other items recognized as medical |
| 24 | | equipment and supplies reimbursable under
this Article and |
| 25 | | shall update such list on a quarterly basis, except that
the |
| 26 | | acquisition costs of all prescription drugs shall be updated no
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| 1 | | less frequently than every 30 days as required by Section |
| 2 | | 5-5.12.
|
| 3 | | The rules and regulations of the Illinois Department shall |
| 4 | | require
that a written statement including the required opinion |
| 5 | | of a physician
shall accompany any claim for reimbursement for |
| 6 | | abortions, or induced
miscarriages or premature births. This |
| 7 | | statement shall indicate what
procedures were used in providing |
| 8 | | such medical services.
|
| 9 | | Notwithstanding any other law to the contrary, the Illinois |
| 10 | | Department shall, within 365 days after July 22, 2013 (the |
| 11 | | effective date of Public Act 98-104), establish procedures to |
| 12 | | permit skilled care facilities licensed under the Nursing Home |
| 13 | | Care Act to submit monthly billing claims for reimbursement |
| 14 | | purposes. Following development of these procedures, the |
| 15 | | Department shall, by July 1, 2016, test the viability of the |
| 16 | | new system and implement any necessary operational or |
| 17 | | structural changes to its information technology platforms in |
| 18 | | order to allow for the direct acceptance and payment of nursing |
| 19 | | home claims. |
| 20 | | Notwithstanding any other law to the contrary, the Illinois |
| 21 | | Department shall, within 365 days after August 15, 2014 (the |
| 22 | | effective date of Public Act 98-963), establish procedures to |
| 23 | | permit ID/DD facilities licensed under the ID/DD Community Care |
| 24 | | Act and MC/DD facilities licensed under the MC/DD Act to submit |
| 25 | | monthly billing claims for reimbursement purposes. Following |
| 26 | | development of these procedures, the Department shall have an |
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| 1 | | additional 365 days to test the viability of the new system and |
| 2 | | to ensure that any necessary operational or structural changes |
| 3 | | to its information technology platforms are implemented. |
| 4 | | The Illinois Department shall require all dispensers of |
| 5 | | medical
services, other than an individual practitioner or |
| 6 | | group of practitioners,
desiring to participate in the Medical |
| 7 | | Assistance program
established under this Article to disclose |
| 8 | | all financial, beneficial,
ownership, equity, surety or other |
| 9 | | interests in any and all firms,
corporations, partnerships, |
| 10 | | associations, business enterprises, joint
ventures, agencies, |
| 11 | | institutions or other legal entities providing any
form of |
| 12 | | health care services in this State under this Article.
|
| 13 | | The Illinois Department may require that all dispensers of |
| 14 | | medical
services desiring to participate in the medical |
| 15 | | assistance program
established under this Article disclose, |
| 16 | | under such terms and conditions as
the Illinois Department may |
| 17 | | by rule establish, all inquiries from clients
and attorneys |
| 18 | | regarding medical bills paid by the Illinois Department, which
|
| 19 | | inquiries could indicate potential existence of claims or liens |
| 20 | | for the
Illinois Department.
|
| 21 | | Enrollment of a vendor
shall be
subject to a provisional |
| 22 | | period and shall be conditional for one year. During the period |
| 23 | | of conditional enrollment, the Department may
terminate the |
| 24 | | vendor's eligibility to participate in, or may disenroll the |
| 25 | | vendor from, the medical assistance
program without cause. |
| 26 | | Unless otherwise specified, such termination of eligibility or |
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| 1 | | disenrollment is not subject to the
Department's hearing |
| 2 | | process.
However, a disenrolled vendor may reapply without |
| 3 | | penalty.
|
| 4 | | The Department has the discretion to limit the conditional |
| 5 | | enrollment period for vendors based upon category of risk of |
| 6 | | the vendor. |
| 7 | | Prior to enrollment and during the conditional enrollment |
| 8 | | period in the medical assistance program, all vendors shall be |
| 9 | | subject to enhanced oversight, screening, and review based on |
| 10 | | the risk of fraud, waste, and abuse that is posed by the |
| 11 | | category of risk of the vendor. The Illinois Department shall |
| 12 | | establish the procedures for oversight, screening, and review, |
| 13 | | which may include, but need not be limited to: criminal and |
| 14 | | financial background checks; fingerprinting; license, |
| 15 | | certification, and authorization verifications; unscheduled or |
| 16 | | unannounced site visits; database checks; prepayment audit |
| 17 | | reviews; audits; payment caps; payment suspensions; and other |
| 18 | | screening as required by federal or State law. |
| 19 | | The Department shall define or specify the following: (i) |
| 20 | | by provider notice, the "category of risk of the vendor" for |
| 21 | | each type of vendor, which shall take into account the level of |
| 22 | | screening applicable to a particular category of vendor under |
| 23 | | federal law and regulations; (ii) by rule or provider notice, |
| 24 | | the maximum length of the conditional enrollment period for |
| 25 | | each category of risk of the vendor; and (iii) by rule, the |
| 26 | | hearing rights, if any, afforded to a vendor in each category |
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| 1 | | of risk of the vendor that is terminated or disenrolled during |
| 2 | | the conditional enrollment period. |
| 3 | | To be eligible for payment consideration, a vendor's |
| 4 | | payment claim or bill, either as an initial claim or as a |
| 5 | | resubmitted claim following prior rejection, must be received |
| 6 | | by the Illinois Department, or its fiscal intermediary, no |
| 7 | | later than 180 days after the latest date on the claim on which |
| 8 | | medical goods or services were provided, with the following |
| 9 | | exceptions: |
| 10 | | (1) In the case of a provider whose enrollment is in |
| 11 | | process by the Illinois Department, the 180-day period |
| 12 | | shall not begin until the date on the written notice from |
| 13 | | the Illinois Department that the provider enrollment is |
| 14 | | complete. |
| 15 | | (2) In the case of errors attributable to the Illinois |
| 16 | | Department or any of its claims processing intermediaries |
| 17 | | which result in an inability to receive, process, or |
| 18 | | adjudicate a claim, the 180-day period shall not begin |
| 19 | | until the provider has been notified of the error. |
| 20 | | (3) In the case of a provider for whom the Illinois |
| 21 | | Department initiates the monthly billing process. |
| 22 | | (4) In the case of a provider operated by a unit of |
| 23 | | local government with a population exceeding 3,000,000 |
| 24 | | when local government funds finance federal participation |
| 25 | | for claims payments. |
| 26 | | For claims for services rendered during a period for which |
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| 1 | | a recipient received retroactive eligibility, claims must be |
| 2 | | filed within 180 days after the Department determines the |
| 3 | | applicant is eligible. For claims for which the Illinois |
| 4 | | Department is not the primary payer, claims must be submitted |
| 5 | | to the Illinois Department within 180 days after the final |
| 6 | | adjudication by the primary payer. |
| 7 | | In the case of long term care facilities, within 5 days of |
| 8 | | receipt by the facility of required prescreening information, |
| 9 | | data for new admissions shall be entered into the Medical |
| 10 | | Electronic Data Interchange (MEDI) or the Recipient |
| 11 | | Eligibility Verification (REV) System or successor system, and |
| 12 | | within 15 days of receipt by the facility of required |
| 13 | | prescreening information, admission documents shall be |
| 14 | | submitted through MEDI or REV or shall be submitted directly to |
| 15 | | the Department of Human Services using required admission |
| 16 | | forms. Effective September
1, 2014, admission documents, |
| 17 | | including all prescreening
information, must be submitted |
| 18 | | through MEDI or REV. Confirmation numbers assigned to an |
| 19 | | accepted transaction shall be retained by a facility to verify |
| 20 | | timely submittal. Once an admission transaction has been |
| 21 | | completed, all resubmitted claims following prior rejection |
| 22 | | are subject to receipt no later than 180 days after the |
| 23 | | admission transaction has been completed. |
| 24 | | Claims that are not submitted and received in compliance |
| 25 | | with the foregoing requirements shall not be eligible for |
| 26 | | payment under the medical assistance program, and the State |
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| 1 | | shall have no liability for payment of those claims. |
| 2 | | To the extent consistent with applicable information and |
| 3 | | privacy, security, and disclosure laws, State and federal |
| 4 | | agencies and departments shall provide the Illinois Department |
| 5 | | access to confidential and other information and data necessary |
| 6 | | to perform eligibility and payment verifications and other |
| 7 | | Illinois Department functions. This includes, but is not |
| 8 | | limited to: information pertaining to licensure; |
| 9 | | certification; earnings; immigration status; citizenship; wage |
| 10 | | reporting; unearned and earned income; pension income; |
| 11 | | employment; supplemental security income; social security |
| 12 | | numbers; National Provider Identifier (NPI) numbers; the |
| 13 | | National Practitioner Data Bank (NPDB); program and agency |
| 14 | | exclusions; taxpayer identification numbers; tax delinquency; |
| 15 | | corporate information; and death records. |
| 16 | | The Illinois Department shall enter into agreements with |
| 17 | | State agencies and departments, and is authorized to enter into |
| 18 | | agreements with federal agencies and departments, under which |
| 19 | | such agencies and departments shall share data necessary for |
| 20 | | medical assistance program integrity functions and oversight. |
| 21 | | The Illinois Department shall develop, in cooperation with |
| 22 | | other State departments and agencies, and in compliance with |
| 23 | | applicable federal laws and regulations, appropriate and |
| 24 | | effective methods to share such data. At a minimum, and to the |
| 25 | | extent necessary to provide data sharing, the Illinois |
| 26 | | Department shall enter into agreements with State agencies and |
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| 1 | | departments, and is authorized to enter into agreements with |
| 2 | | federal agencies and departments, including but not limited to: |
| 3 | | the Secretary of State; the Department of Revenue; the |
| 4 | | Department of Public Health; the Department of Human Services; |
| 5 | | and the Department of Financial and Professional Regulation. |
| 6 | | Beginning in fiscal year 2013, the Illinois Department |
| 7 | | shall set forth a request for information to identify the |
| 8 | | benefits of a pre-payment, post-adjudication, and post-edit |
| 9 | | claims system with the goals of streamlining claims processing |
| 10 | | and provider reimbursement, reducing the number of pending or |
| 11 | | rejected claims, and helping to ensure a more transparent |
| 12 | | adjudication process through the utilization of: (i) provider |
| 13 | | data verification and provider screening technology; and (ii) |
| 14 | | clinical code editing; and (iii) pre-pay, pre- or |
| 15 | | post-adjudicated predictive modeling with an integrated case |
| 16 | | management system with link analysis. Such a request for |
| 17 | | information shall not be considered as a request for proposal |
| 18 | | or as an obligation on the part of the Illinois Department to |
| 19 | | take any action or acquire any products or services. |
| 20 | | The Illinois Department shall establish policies, |
| 21 | | procedures,
standards and criteria by rule for the acquisition, |
| 22 | | repair and replacement
of orthotic and prosthetic devices and |
| 23 | | durable medical equipment. Such
rules shall provide, but not be |
| 24 | | limited to, the following services: (1)
immediate repair or |
| 25 | | replacement of such devices by recipients; and (2) rental, |
| 26 | | lease, purchase or lease-purchase of
durable medical equipment |
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| 1 | | in a cost-effective manner, taking into
consideration the |
| 2 | | recipient's medical prognosis, the extent of the
recipient's |
| 3 | | needs, and the requirements and costs for maintaining such
|
| 4 | | equipment. Subject to prior approval, such rules shall enable a |
| 5 | | recipient to temporarily acquire and
use alternative or |
| 6 | | substitute devices or equipment pending repairs or
|
| 7 | | replacements of any device or equipment previously authorized |
| 8 | | for such
recipient by the Department. Notwithstanding any |
| 9 | | provision of Section 5-5f to the contrary, the Department may, |
| 10 | | by rule, exempt certain replacement wheelchair parts from prior |
| 11 | | approval and, for wheelchairs, wheelchair parts, wheelchair |
| 12 | | accessories, and related seating and positioning items, |
| 13 | | determine the wholesale price by methods other than actual |
| 14 | | acquisition costs. |
| 15 | | The Department shall require, by rule, all providers of |
| 16 | | durable medical equipment to be accredited by an accreditation |
| 17 | | organization approved by the federal Centers for Medicare and |
| 18 | | Medicaid Services and recognized by the Department in order to |
| 19 | | bill the Department for providing durable medical equipment to |
| 20 | | recipients. No later than 15 months after the effective date of |
| 21 | | the rule adopted pursuant to this paragraph, all providers must |
| 22 | | meet the accreditation requirement.
|
| 23 | | The Department shall execute, relative to the nursing home |
| 24 | | prescreening
project, written inter-agency agreements with the |
| 25 | | Department of Human
Services and the Department on Aging, to |
| 26 | | effect the following: (i) intake
procedures and common |
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| 1 | | eligibility criteria for those persons who are receiving
|
| 2 | | non-institutional services; and (ii) the establishment and |
| 3 | | development of
non-institutional services in areas of the State |
| 4 | | where they are not currently
available or are undeveloped; and |
| 5 | | (iii) notwithstanding any other provision of law, subject to |
| 6 | | federal approval, on and after July 1, 2012, an increase in the |
| 7 | | determination of need (DON) scores from 29 to 37 for applicants |
| 8 | | for institutional and home and community-based long term care; |
| 9 | | if and only if federal approval is not granted, the Department |
| 10 | | may, in conjunction with other affected agencies, implement |
| 11 | | utilization controls or changes in benefit packages to |
| 12 | | effectuate a similar savings amount for this population; and |
| 13 | | (iv) no later than July 1, 2013, minimum level of care |
| 14 | | eligibility criteria for institutional and home and |
| 15 | | community-based long term care; and (v) no later than October |
| 16 | | 1, 2013, establish procedures to permit long term care |
| 17 | | providers access to eligibility scores for individuals with an |
| 18 | | admission date who are seeking or receiving services from the |
| 19 | | long term care provider. In order to select the minimum level |
| 20 | | of care eligibility criteria, the Governor shall establish a |
| 21 | | workgroup that includes affected agency representatives and |
| 22 | | stakeholders representing the institutional and home and |
| 23 | | community-based long term care interests. This Section shall |
| 24 | | not restrict the Department from implementing lower level of |
| 25 | | care eligibility criteria for community-based services in |
| 26 | | circumstances where federal approval has been granted.
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| 1 | | The Illinois Department shall develop and operate, in |
| 2 | | cooperation
with other State Departments and agencies and in |
| 3 | | compliance with
applicable federal laws and regulations, |
| 4 | | appropriate and effective
systems of health care evaluation and |
| 5 | | programs for monitoring of
utilization of health care services |
| 6 | | and facilities, as it affects
persons eligible for medical |
| 7 | | assistance under this Code.
|
| 8 | | The Illinois Department shall report annually to the |
| 9 | | General Assembly,
no later than the second Friday in April of |
| 10 | | 1979 and each year
thereafter, in regard to:
|
| 11 | | (a) actual statistics and trends in utilization of |
| 12 | | medical services by
public aid recipients;
|
| 13 | | (b) actual statistics and trends in the provision of |
| 14 | | the various medical
services by medical vendors;
|
| 15 | | (c) current rate structures and proposed changes in |
| 16 | | those rate structures
for the various medical vendors; and
|
| 17 | | (d) efforts at utilization review and control by the |
| 18 | | Illinois Department.
|
| 19 | | The period covered by each report shall be the 3 years |
| 20 | | ending on the June
30 prior to the report. The report shall |
| 21 | | include suggested legislation
for consideration by the General |
| 22 | | Assembly. The filing of one copy of the
report with the |
| 23 | | Speaker, one copy with the Minority Leader and one copy
with |
| 24 | | the Clerk of the House of Representatives, one copy with the |
| 25 | | President,
one copy with the Minority Leader and one copy with |
| 26 | | the Secretary of the
Senate, one copy with the Legislative |
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| 1 | | Research Unit, and such additional
copies
with the State |
| 2 | | Government Report Distribution Center for the General
Assembly |
| 3 | | as is required under paragraph (t) of Section 7 of the State
|
| 4 | | Library Act shall be deemed sufficient to comply with this |
| 5 | | Section.
|
| 6 | | Rulemaking authority to implement Public Act 95-1045, if |
| 7 | | any, is conditioned on the rules being adopted in accordance |
| 8 | | with all provisions of the Illinois Administrative Procedure |
| 9 | | Act and all rules and procedures of the Joint Committee on |
| 10 | | Administrative Rules; any purported rule not so adopted, for |
| 11 | | whatever reason, is unauthorized. |
| 12 | | On and after July 1, 2012, the Department shall reduce any |
| 13 | | rate of reimbursement for services or other payments or alter |
| 14 | | any methodologies authorized by this Code to reduce any rate of |
| 15 | | reimbursement for services or other payments in accordance with |
| 16 | | Section 5-5e. |
| 17 | | Because kidney transplantation can be an appropriate, cost |
| 18 | | effective
alternative to renal dialysis when medically |
| 19 | | necessary and notwithstanding the provisions of Section 1-11 of |
| 20 | | this Code, beginning October 1, 2014, the Department shall |
| 21 | | cover kidney transplantation for noncitizens with end-stage |
| 22 | | renal disease who are not eligible for comprehensive medical |
| 23 | | benefits, who meet the residency requirements of Section 5-3 of |
| 24 | | this Code, and who would otherwise meet the financial |
| 25 | | requirements of the appropriate class of eligible persons under |
| 26 | | Section 5-2 of this Code. To qualify for coverage of kidney |
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| 1 | | transplantation, such person must be receiving emergency renal |
| 2 | | dialysis services covered by the Department. Providers under |
| 3 | | this Section shall be prior approved and certified by the |
| 4 | | Department to perform kidney transplantation and the services |
| 5 | | under this Section shall be limited to services associated with |
| 6 | | kidney transplantation. |
| 7 | | Notwithstanding any other provision of this Code to the |
| 8 | | contrary, on or after July 1, 2015, all FDA approved forms of |
| 9 | | medication assisted treatment prescribed for the treatment of |
| 10 | | alcohol dependence or treatment of opioid dependence shall be |
| 11 | | covered under both fee for service and managed care medical |
| 12 | | assistance programs for persons who are otherwise eligible for |
| 13 | | medical assistance under this Article and shall not be subject |
| 14 | | to any (1) utilization control, other than those established |
| 15 | | under the American Society of Addiction Medicine patient |
| 16 | | placement criteria,
(2) prior authorization mandate, or (3) |
| 17 | | lifetime restriction limit
mandate. |
| 18 | | On or after July 1, 2015, opioid antagonists prescribed for |
| 19 | | the treatment of an opioid overdose, including the medication |
| 20 | | product, administration devices, and any pharmacy fees related |
| 21 | | to the dispensing and administration of the opioid antagonist, |
| 22 | | shall be covered under the medical assistance program for |
| 23 | | persons who are otherwise eligible for medical assistance under |
| 24 | | this Article. As used in this Section, "opioid antagonist" |
| 25 | | means a drug that binds to opioid receptors and blocks or |
| 26 | | inhibits the effect of opioids acting on those receptors, |
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| 1 | | including, but not limited to, naloxone hydrochloride or any |
| 2 | | other similarly acting drug approved by the U.S. Food and Drug |
| 3 | | Administration. |
| 4 | | Upon federal approval, the Department shall provide |
| 5 | | coverage and reimbursement for all drugs that are approved for |
| 6 | | marketing by the federal Food and Drug Administration and that |
| 7 | | are recommended by the federal Public Health Service or the |
| 8 | | United States Centers for Disease Control and Prevention for |
| 9 | | pre-exposure prophylaxis and related pre-exposure prophylaxis |
| 10 | | services, including, but not limited to, HIV and sexually |
| 11 | | transmitted infection screening, treatment for sexually |
| 12 | | transmitted infections, medical monitoring, assorted labs, and |
| 13 | | counseling to reduce the likelihood of HIV infection among |
| 14 | | individuals who are not infected with HIV but who are at high |
| 15 | | risk of HIV infection. |
| 16 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; |
| 17 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. |
| 18 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, |
| 19 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; |
| 20 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section |
| 21 | | 20 of P.A. 99-588 for the effective date of P.A. 99-407); |
| 22 | | 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff. |
| 23 | | 7-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895, |
| 24 | | eff. 1-1-17; revised 9-20-16.)
|
| 25 | | (Text of Section after amendment by P.A. 100-538) |
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| 1 | | Sec. 5-5. Medical services. The Illinois Department, by |
| 2 | | rule, shall
determine the quantity and quality of and the rate |
| 3 | | of reimbursement for the
medical assistance for which
payment |
| 4 | | will be authorized, and the medical services to be provided,
|
| 5 | | which may include all or part of the following: (1) inpatient |
| 6 | | hospital
services; (2) outpatient hospital services; (3) other |
| 7 | | laboratory and
X-ray services; (4) skilled nursing home |
| 8 | | services; (5) physicians'
services whether furnished in the |
| 9 | | office, the patient's home, a
hospital, a skilled nursing home, |
| 10 | | or elsewhere; (6) medical care, or any
other type of remedial |
| 11 | | care furnished by licensed practitioners; (7)
home health care |
| 12 | | services; (8) private duty nursing service; (9) clinic
|
| 13 | | services; (10) dental services, including prevention and |
| 14 | | treatment of periodontal disease and dental caries disease for |
| 15 | | pregnant women, provided by an individual licensed to practice |
| 16 | | dentistry or dental surgery; for purposes of this item (10), |
| 17 | | "dental services" means diagnostic, preventive, or corrective |
| 18 | | procedures provided by or under the supervision of a dentist in |
| 19 | | the practice of his or her profession; (11) physical therapy |
| 20 | | and related
services; (12) prescribed drugs, dentures, and |
| 21 | | prosthetic devices; and
eyeglasses prescribed by a physician |
| 22 | | skilled in the diseases of the eye,
or by an optometrist, |
| 23 | | whichever the person may select; (13) other
diagnostic, |
| 24 | | screening, preventive, and rehabilitative services, including |
| 25 | | to ensure that the individual's need for intervention or |
| 26 | | treatment of mental disorders or substance use disorders or |
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| 1 | | co-occurring mental health and substance use disorders is |
| 2 | | determined using a uniform screening, assessment, and |
| 3 | | evaluation process inclusive of criteria, for children and |
| 4 | | adults; for purposes of this item (13), a uniform screening, |
| 5 | | assessment, and evaluation process refers to a process that |
| 6 | | includes an appropriate evaluation and, as warranted, a |
| 7 | | referral; "uniform" does not mean the use of a singular |
| 8 | | instrument, tool, or process that all must utilize; (14)
|
| 9 | | transportation and such other expenses as may be necessary; |
| 10 | | (15) medical
treatment of sexual assault survivors, as defined |
| 11 | | in
Section 1a of the Sexual Assault Survivors Emergency |
| 12 | | Treatment Act, for
injuries sustained as a result of the sexual |
| 13 | | assault, including
examinations and laboratory tests to |
| 14 | | discover evidence which may be used in
criminal proceedings |
| 15 | | arising from the sexual assault; (16) the
diagnosis and |
| 16 | | treatment of sickle cell anemia; and (17)
any other medical |
| 17 | | care, and any other type of remedial care recognized
under the |
| 18 | | laws of this State, except as provided in the No Taxpayer |
| 19 | | Funding for Abortion Act. The Illinois Department, by rule, |
| 20 | | shall prohibit any physician from providing medical assistance |
| 21 | | to anyone eligible therefor under this Code where such |
| 22 | | physician has been found guilty of performing an abortion |
| 23 | | procedure in a willful and wanton manner upon a woman who was |
| 24 | | not pregnant at the time such abortion procedure was performed. |
| 25 | | The term "any other type of remedial care" shall
include |
| 26 | | nursing care and nursing home service for persons who rely on
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| 1 | | treatment by spiritual means alone through prayer for healing.
|
| 2 | | Notwithstanding any other provision of this Section, a |
| 3 | | comprehensive
tobacco use cessation program that includes |
| 4 | | purchasing prescription drugs or
prescription medical devices |
| 5 | | approved by the Food and Drug Administration shall
be covered |
| 6 | | under the medical assistance
program under this Article for |
| 7 | | persons who are otherwise eligible for
assistance under this |
| 8 | | Article.
|
| 9 | | Notwithstanding any other provision of this Code, |
| 10 | | reproductive health care that is otherwise legal in Illinois |
| 11 | | shall be covered under the medical assistance program for |
| 12 | | persons who are otherwise eligible for medical assistance under |
| 13 | | this Article, except as provided in the No Taxpayer Funding for |
| 14 | | Abortion Act. |
| 15 | | Notwithstanding any other provision of this Code, the |
| 16 | | Illinois
Department may not require, as a condition of payment |
| 17 | | for any laboratory
test authorized under this Article, that a |
| 18 | | physician's handwritten signature
appear on the laboratory |
| 19 | | test order form. The Illinois Department may,
however, impose |
| 20 | | other appropriate requirements regarding laboratory test
order |
| 21 | | documentation.
|
| 22 | | Upon receipt of federal approval of an amendment to the |
| 23 | | Illinois Title XIX State Plan for this purpose, the Department |
| 24 | | shall authorize the Chicago Public Schools (CPS) to procure a |
| 25 | | vendor or vendors to manufacture eyeglasses for individuals |
| 26 | | enrolled in a school within the CPS system. CPS shall ensure |
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| 1 | | that its vendor or vendors are enrolled as providers in the |
| 2 | | medical assistance program and in any capitated Medicaid |
| 3 | | managed care entity (MCE) serving individuals enrolled in a |
| 4 | | school within the CPS system. Under any contract procured under |
| 5 | | this provision, the vendor or vendors must serve only |
| 6 | | individuals enrolled in a school within the CPS system. Claims |
| 7 | | for services provided by CPS's vendor or vendors to recipients |
| 8 | | of benefits in the medical assistance program under this Code, |
| 9 | | the Children's Health Insurance Program, or the Covering ALL |
| 10 | | KIDS Health Insurance Program shall be submitted to the |
| 11 | | Department or the MCE in which the individual is enrolled for |
| 12 | | payment and shall be reimbursed at the Department's or the |
| 13 | | MCE's established rates or rate methodologies for eyeglasses. |
| 14 | | On and after July 1, 2012, the Department of Healthcare and |
| 15 | | Family Services may provide the following services to
persons
|
| 16 | | eligible for assistance under this Article who are |
| 17 | | participating in
education, training or employment programs |
| 18 | | operated by the Department of Human
Services as successor to |
| 19 | | the Department of Public Aid:
|
| 20 | | (1) dental services provided by or under the |
| 21 | | supervision of a dentist; and
|
| 22 | | (2) eyeglasses prescribed by a physician skilled in the |
| 23 | | diseases of the
eye, or by an optometrist, whichever the |
| 24 | | person may select.
|
| 25 | | Notwithstanding any other provision of this Code and |
| 26 | | subject to federal approval, the Department may adopt rules to |
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| 1 | | allow a dentist who is volunteering his or her service at no |
| 2 | | cost to render dental services through an enrolled |
| 3 | | not-for-profit health clinic without the dentist personally |
| 4 | | enrolling as a participating provider in the medical assistance |
| 5 | | program. A not-for-profit health clinic shall include a public |
| 6 | | health clinic or Federally Qualified Health Center or other |
| 7 | | enrolled provider, as determined by the Department, through |
| 8 | | which dental services covered under this Section are performed. |
| 9 | | The Department shall establish a process for payment of claims |
| 10 | | for reimbursement for covered dental services rendered under |
| 11 | | this provision. |
| 12 | | The Illinois Department, by rule, may distinguish and |
| 13 | | classify the
medical services to be provided only in accordance |
| 14 | | with the classes of
persons designated in Section 5-2.
|
| 15 | | The Department of Healthcare and Family Services must |
| 16 | | provide coverage and reimbursement for amino acid-based |
| 17 | | elemental formulas, regardless of delivery method, for the |
| 18 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
| 19 | | short bowel syndrome when the prescribing physician has issued |
| 20 | | a written order stating that the amino acid-based elemental |
| 21 | | formula is medically necessary.
|
| 22 | | The Illinois Department shall authorize the provision of, |
| 23 | | and shall
authorize payment for, screening by low-dose |
| 24 | | mammography for the presence of
occult breast cancer for women |
| 25 | | 35 years of age or older who are eligible
for medical |
| 26 | | assistance under this Article, as follows: |
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| 1 | | (A) A baseline
mammogram for women 35 to 39 years of |
| 2 | | age.
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| 3 | | (B) An annual mammogram for women 40 years of age or |
| 4 | | older. |
| 5 | | (C) A mammogram at the age and intervals considered |
| 6 | | medically necessary by the woman's health care provider for |
| 7 | | women under 40 years of age and having a family history of |
| 8 | | breast cancer, prior personal history of breast cancer, |
| 9 | | positive genetic testing, or other risk factors. |
| 10 | | (D) A comprehensive ultrasound screening of an entire |
| 11 | | breast or breasts if a mammogram demonstrates |
| 12 | | heterogeneous or dense breast tissue, when medically |
| 13 | | necessary as determined by a physician licensed to practice |
| 14 | | medicine in all of its branches. |
| 15 | | (E) A screening MRI when medically necessary, as |
| 16 | | determined by a physician licensed to practice medicine in |
| 17 | | all of its branches. |
| 18 | | All screenings
shall
include a physical breast exam, |
| 19 | | instruction on self-examination and
information regarding the |
| 20 | | frequency of self-examination and its value as a
preventative |
| 21 | | tool. For purposes of this Section, "low-dose mammography" |
| 22 | | means
the x-ray examination of the breast using equipment |
| 23 | | dedicated specifically
for mammography, including the x-ray |
| 24 | | tube, filter, compression device,
and image receptor, with an |
| 25 | | average radiation exposure delivery
of less than one rad per |
| 26 | | breast for 2 views of an average size breast.
The term also |
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| 1 | | includes digital mammography and includes breast |
| 2 | | tomosynthesis. As used in this Section, the term "breast |
| 3 | | tomosynthesis" means a radiologic procedure that involves the |
| 4 | | acquisition of projection images over the stationary breast to |
| 5 | | produce cross-sectional digital three-dimensional images of |
| 6 | | the breast. If, at any time, the Secretary of the United States |
| 7 | | Department of Health and Human Services, or its successor |
| 8 | | agency, promulgates rules or regulations to be published in the |
| 9 | | Federal Register or publishes a comment in the Federal Register |
| 10 | | or issues an opinion, guidance, or other action that would |
| 11 | | require the State, pursuant to any provision of the Patient |
| 12 | | Protection and Affordable Care Act (Public Law 111-148), |
| 13 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any |
| 14 | | successor provision, to defray the cost of any coverage for |
| 15 | | breast tomosynthesis outlined in this paragraph, then the |
| 16 | | requirement that an insurer cover breast tomosynthesis is |
| 17 | | inoperative other than any such coverage authorized under |
| 18 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and |
| 19 | | the State shall not assume any obligation for the cost of |
| 20 | | coverage for breast tomosynthesis set forth in this paragraph.
|
| 21 | | On and after January 1, 2016, the Department shall ensure |
| 22 | | that all networks of care for adult clients of the Department |
| 23 | | include access to at least one breast imaging Center of Imaging |
| 24 | | Excellence as certified by the American College of Radiology. |
| 25 | | On and after January 1, 2012, providers participating in a |
| 26 | | quality improvement program approved by the Department shall be |
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| 1 | | reimbursed for screening and diagnostic mammography at the same |
| 2 | | rate as the Medicare program's rates, including the increased |
| 3 | | reimbursement for digital mammography. |
| 4 | | The Department shall convene an expert panel including |
| 5 | | representatives of hospitals, free-standing mammography |
| 6 | | facilities, and doctors, including radiologists, to establish |
| 7 | | quality standards for mammography. |
| 8 | | On and after January 1, 2017, providers participating in a |
| 9 | | breast cancer treatment quality improvement program approved |
| 10 | | by the Department shall be reimbursed for breast cancer |
| 11 | | treatment at a rate that is no lower than 95% of the Medicare |
| 12 | | program's rates for the data elements included in the breast |
| 13 | | cancer treatment quality program. |
| 14 | | The Department shall convene an expert panel, including |
| 15 | | representatives of hospitals, free standing breast cancer |
| 16 | | treatment centers, breast cancer quality organizations, and |
| 17 | | doctors, including breast surgeons, reconstructive breast |
| 18 | | surgeons, oncologists, and primary care providers to establish |
| 19 | | quality standards for breast cancer treatment. |
| 20 | | Subject to federal approval, the Department shall |
| 21 | | establish a rate methodology for mammography at federally |
| 22 | | qualified health centers and other encounter-rate clinics. |
| 23 | | These clinics or centers may also collaborate with other |
| 24 | | hospital-based mammography facilities. By January 1, 2016, the |
| 25 | | Department shall report to the General Assembly on the status |
| 26 | | of the provision set forth in this paragraph. |
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| 1 | | The Department shall establish a methodology to remind |
| 2 | | women who are age-appropriate for screening mammography, but |
| 3 | | who have not received a mammogram within the previous 18 |
| 4 | | months, of the importance and benefit of screening mammography. |
| 5 | | The Department shall work with experts in breast cancer |
| 6 | | outreach and patient navigation to optimize these reminders and |
| 7 | | shall establish a methodology for evaluating their |
| 8 | | effectiveness and modifying the methodology based on the |
| 9 | | evaluation. |
| 10 | | The Department shall establish a performance goal for |
| 11 | | primary care providers with respect to their female patients |
| 12 | | over age 40 receiving an annual mammogram. This performance |
| 13 | | goal shall be used to provide additional reimbursement in the |
| 14 | | form of a quality performance bonus to primary care providers |
| 15 | | who meet that goal. |
| 16 | | The Department shall devise a means of case-managing or |
| 17 | | patient navigation for beneficiaries diagnosed with breast |
| 18 | | cancer. This program shall initially operate as a pilot program |
| 19 | | in areas of the State with the highest incidence of mortality |
| 20 | | related to breast cancer. At least one pilot program site shall |
| 21 | | be in the metropolitan Chicago area and at least one site shall |
| 22 | | be outside the metropolitan Chicago area. On or after July 1, |
| 23 | | 2016, the pilot program shall be expanded to include one site |
| 24 | | in western Illinois, one site in southern Illinois, one site in |
| 25 | | central Illinois, and 4 sites within metropolitan Chicago. An |
| 26 | | evaluation of the pilot program shall be carried out measuring |
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| 1 | | health outcomes and cost of care for those served by the pilot |
| 2 | | program compared to similarly situated patients who are not |
| 3 | | served by the pilot program. |
| 4 | | The Department shall require all networks of care to |
| 5 | | develop a means either internally or by contract with experts |
| 6 | | in navigation and community outreach to navigate cancer |
| 7 | | patients to comprehensive care in a timely fashion. The |
| 8 | | Department shall require all networks of care to include access |
| 9 | | for patients diagnosed with cancer to at least one academic |
| 10 | | commission on cancer-accredited cancer program as an |
| 11 | | in-network covered benefit. |
| 12 | | Any medical or health care provider shall immediately |
| 13 | | recommend, to
any pregnant woman who is being provided prenatal |
| 14 | | services and is suspected
of drug abuse or is addicted as |
| 15 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
| 16 | | Act, referral to a local substance abuse treatment provider
|
| 17 | | licensed by the Department of Human Services or to a licensed
|
| 18 | | hospital which provides substance abuse treatment services. |
| 19 | | The Department of Healthcare and Family Services
shall assure |
| 20 | | coverage for the cost of treatment of the drug abuse or
|
| 21 | | addiction for pregnant recipients in accordance with the |
| 22 | | Illinois Medicaid
Program in conjunction with the Department of |
| 23 | | Human Services.
|
| 24 | | All medical providers providing medical assistance to |
| 25 | | pregnant women
under this Code shall receive information from |
| 26 | | the Department on the
availability of services under the Drug |
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| 1 | | Free Families with a Future or any
comparable program providing |
| 2 | | case management services for addicted women,
including |
| 3 | | information on appropriate referrals for other social services
|
| 4 | | that may be needed by addicted women in addition to treatment |
| 5 | | for addiction.
|
| 6 | | The Illinois Department, in cooperation with the |
| 7 | | Departments of Human
Services (as successor to the Department |
| 8 | | of Alcoholism and Substance
Abuse) and Public Health, through a |
| 9 | | public awareness campaign, may
provide information concerning |
| 10 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
| 11 | | health care, and other pertinent programs directed at
reducing |
| 12 | | the number of drug-affected infants born to recipients of |
| 13 | | medical
assistance.
|
| 14 | | Neither the Department of Healthcare and Family Services |
| 15 | | nor the Department of Human
Services shall sanction the |
| 16 | | recipient solely on the basis of
her substance abuse.
|
| 17 | | The Illinois Department shall establish such regulations |
| 18 | | governing
the dispensing of health services under this Article |
| 19 | | as it shall deem
appropriate. The Department
should
seek the |
| 20 | | advice of formal professional advisory committees appointed by
|
| 21 | | the Director of the Illinois Department for the purpose of |
| 22 | | providing regular
advice on policy and administrative matters, |
| 23 | | information dissemination and
educational activities for |
| 24 | | medical and health care providers, and
consistency in |
| 25 | | procedures to the Illinois Department.
|
| 26 | | The Illinois Department may develop and contract with |
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| 1 | | Partnerships of
medical providers to arrange medical services |
| 2 | | for persons eligible under
Section 5-2 of this Code. |
| 3 | | Implementation of this Section may be by
demonstration projects |
| 4 | | in certain geographic areas. The Partnership shall
be |
| 5 | | represented by a sponsor organization. The Department, by rule, |
| 6 | | shall
develop qualifications for sponsors of Partnerships. |
| 7 | | Nothing in this
Section shall be construed to require that the |
| 8 | | sponsor organization be a
medical organization.
|
| 9 | | The sponsor must negotiate formal written contracts with |
| 10 | | medical
providers for physician services, inpatient and |
| 11 | | outpatient hospital care,
home health services, treatment for |
| 12 | | alcoholism and substance abuse, and
other services determined |
| 13 | | necessary by the Illinois Department by rule for
delivery by |
| 14 | | Partnerships. Physician services must include prenatal and
|
| 15 | | obstetrical care. The Illinois Department shall reimburse |
| 16 | | medical services
delivered by Partnership providers to clients |
| 17 | | in target areas according to
provisions of this Article and the |
| 18 | | Illinois Health Finance Reform Act,
except that:
|
| 19 | | (1) Physicians participating in a Partnership and |
| 20 | | providing certain
services, which shall be determined by |
| 21 | | the Illinois Department, to persons
in areas covered by the |
| 22 | | Partnership may receive an additional surcharge
for such |
| 23 | | services.
|
| 24 | | (2) The Department may elect to consider and negotiate |
| 25 | | financial
incentives to encourage the development of |
| 26 | | Partnerships and the efficient
delivery of medical care.
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| 1 | | (3) Persons receiving medical services through |
| 2 | | Partnerships may receive
medical and case management |
| 3 | | services above the level usually offered
through the |
| 4 | | medical assistance program.
|
| 5 | | Medical providers shall be required to meet certain |
| 6 | | qualifications to
participate in Partnerships to ensure the |
| 7 | | delivery of high quality medical
services. These |
| 8 | | qualifications shall be determined by rule of the Illinois
|
| 9 | | Department and may be higher than qualifications for |
| 10 | | participation in the
medical assistance program. Partnership |
| 11 | | sponsors may prescribe reasonable
additional qualifications |
| 12 | | for participation by medical providers, only with
the prior |
| 13 | | written approval of the Illinois Department.
|
| 14 | | Nothing in this Section shall limit the free choice of |
| 15 | | practitioners,
hospitals, and other providers of medical |
| 16 | | services by clients.
In order to ensure patient freedom of |
| 17 | | choice, the Illinois Department shall
immediately promulgate |
| 18 | | all rules and take all other necessary actions so that
provided |
| 19 | | services may be accessed from therapeutically certified |
| 20 | | optometrists
to the full extent of the Illinois Optometric |
| 21 | | Practice Act of 1987 without
discriminating between service |
| 22 | | providers.
|
| 23 | | The Department shall apply for a waiver from the United |
| 24 | | States Health
Care Financing Administration to allow for the |
| 25 | | implementation of
Partnerships under this Section.
|
| 26 | | The Illinois Department shall require health care |
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| 1 | | providers to maintain
records that document the medical care |
| 2 | | and services provided to recipients
of Medical Assistance under |
| 3 | | this Article. Such records must be retained for a period of not |
| 4 | | less than 6 years from the date of service or as provided by |
| 5 | | applicable State law, whichever period is longer, except that |
| 6 | | if an audit is initiated within the required retention period |
| 7 | | then the records must be retained until the audit is completed |
| 8 | | and every exception is resolved. The Illinois Department shall
|
| 9 | | require health care providers to make available, when |
| 10 | | authorized by the
patient, in writing, the medical records in a |
| 11 | | timely fashion to other
health care providers who are treating |
| 12 | | or serving persons eligible for
Medical Assistance under this |
| 13 | | Article. All dispensers of medical services
shall be required |
| 14 | | to maintain and retain business and professional records
|
| 15 | | sufficient to fully and accurately document the nature, scope, |
| 16 | | details and
receipt of the health care provided to persons |
| 17 | | eligible for medical
assistance under this Code, in accordance |
| 18 | | with regulations promulgated by
the Illinois Department. The |
| 19 | | rules and regulations shall require that proof
of the receipt |
| 20 | | of prescription drugs, dentures, prosthetic devices and
|
| 21 | | eyeglasses by eligible persons under this Section accompany |
| 22 | | each claim
for reimbursement submitted by the dispenser of such |
| 23 | | medical services.
No such claims for reimbursement shall be |
| 24 | | approved for payment by the Illinois
Department without such |
| 25 | | proof of receipt, unless the Illinois Department
shall have put |
| 26 | | into effect and shall be operating a system of post-payment
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| 1 | | audit and review which shall, on a sampling basis, be deemed |
| 2 | | adequate by
the Illinois Department to assure that such drugs, |
| 3 | | dentures, prosthetic
devices and eyeglasses for which payment |
| 4 | | is being made are actually being
received by eligible |
| 5 | | recipients. Within 90 days after September 16, 1984 (the |
| 6 | | effective date of Public Act 83-1439), the Illinois Department |
| 7 | | shall establish a
current list of acquisition costs for all |
| 8 | | prosthetic devices and any
other items recognized as medical |
| 9 | | equipment and supplies reimbursable under
this Article and |
| 10 | | shall update such list on a quarterly basis, except that
the |
| 11 | | acquisition costs of all prescription drugs shall be updated no
|
| 12 | | less frequently than every 30 days as required by Section |
| 13 | | 5-5.12.
|
| 14 | | The rules and regulations of the Illinois Department shall |
| 15 | | require that a written statement including the required opinion |
| 16 | | of a physician shall accompany any claim for reimbursement for |
| 17 | | abortions or induced miscarriages or premature births. This |
| 18 | | statement shall indicate what procedures were used in providing |
| 19 | | such medical services. |
| 20 | | Notwithstanding any other law to the contrary, the Illinois |
| 21 | | Department shall, within 365 days after July 22, 2013 (the |
| 22 | | effective date of Public Act 98-104), establish procedures to |
| 23 | | permit skilled care facilities licensed under the Nursing Home |
| 24 | | Care Act to submit monthly billing claims for reimbursement |
| 25 | | purposes. Following development of these procedures, the |
| 26 | | Department shall, by July 1, 2016, test the viability of the |
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| 1 | | new system and implement any necessary operational or |
| 2 | | structural changes to its information technology platforms in |
| 3 | | order to allow for the direct acceptance and payment of nursing |
| 4 | | home claims. |
| 5 | | Notwithstanding any other law to the contrary, the Illinois |
| 6 | | Department shall, within 365 days after August 15, 2014 (the |
| 7 | | effective date of Public Act 98-963), establish procedures to |
| 8 | | permit ID/DD facilities licensed under the ID/DD Community Care |
| 9 | | Act and MC/DD facilities licensed under the MC/DD Act to submit |
| 10 | | monthly billing claims for reimbursement purposes. Following |
| 11 | | development of these procedures, the Department shall have an |
| 12 | | additional 365 days to test the viability of the new system and |
| 13 | | to ensure that any necessary operational or structural changes |
| 14 | | to its information technology platforms are implemented. |
| 15 | | The Illinois Department shall require all dispensers of |
| 16 | | medical
services, other than an individual practitioner or |
| 17 | | group of practitioners,
desiring to participate in the Medical |
| 18 | | Assistance program
established under this Article to disclose |
| 19 | | all financial, beneficial,
ownership, equity, surety or other |
| 20 | | interests in any and all firms,
corporations, partnerships, |
| 21 | | associations, business enterprises, joint
ventures, agencies, |
| 22 | | institutions or other legal entities providing any
form of |
| 23 | | health care services in this State under this Article.
|
| 24 | | The Illinois Department may require that all dispensers of |
| 25 | | medical
services desiring to participate in the medical |
| 26 | | assistance program
established under this Article disclose, |
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| 1 | | under such terms and conditions as
the Illinois Department may |
| 2 | | by rule establish, all inquiries from clients
and attorneys |
| 3 | | regarding medical bills paid by the Illinois Department, which
|
| 4 | | inquiries could indicate potential existence of claims or liens |
| 5 | | for the
Illinois Department.
|
| 6 | | Enrollment of a vendor
shall be
subject to a provisional |
| 7 | | period and shall be conditional for one year. During the period |
| 8 | | of conditional enrollment, the Department may
terminate the |
| 9 | | vendor's eligibility to participate in, or may disenroll the |
| 10 | | vendor from, the medical assistance
program without cause. |
| 11 | | Unless otherwise specified, such termination of eligibility or |
| 12 | | disenrollment is not subject to the
Department's hearing |
| 13 | | process.
However, a disenrolled vendor may reapply without |
| 14 | | penalty.
|
| 15 | | The Department has the discretion to limit the conditional |
| 16 | | enrollment period for vendors based upon category of risk of |
| 17 | | the vendor. |
| 18 | | Prior to enrollment and during the conditional enrollment |
| 19 | | period in the medical assistance program, all vendors shall be |
| 20 | | subject to enhanced oversight, screening, and review based on |
| 21 | | the risk of fraud, waste, and abuse that is posed by the |
| 22 | | category of risk of the vendor. The Illinois Department shall |
| 23 | | establish the procedures for oversight, screening, and review, |
| 24 | | which may include, but need not be limited to: criminal and |
| 25 | | financial background checks; fingerprinting; license, |
| 26 | | certification, and authorization verifications; unscheduled or |
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| 1 | | unannounced site visits; database checks; prepayment audit |
| 2 | | reviews; audits; payment caps; payment suspensions; and other |
| 3 | | screening as required by federal or State law. |
| 4 | | The Department shall define or specify the following: (i) |
| 5 | | by provider notice, the "category of risk of the vendor" for |
| 6 | | each type of vendor, which shall take into account the level of |
| 7 | | screening applicable to a particular category of vendor under |
| 8 | | federal law and regulations; (ii) by rule or provider notice, |
| 9 | | the maximum length of the conditional enrollment period for |
| 10 | | each category of risk of the vendor; and (iii) by rule, the |
| 11 | | hearing rights, if any, afforded to a vendor in each category |
| 12 | | of risk of the vendor that is terminated or disenrolled during |
| 13 | | the conditional enrollment period. |
| 14 | | To be eligible for payment consideration, a vendor's |
| 15 | | payment claim or bill, either as an initial claim or as a |
| 16 | | resubmitted claim following prior rejection, must be received |
| 17 | | by the Illinois Department, or its fiscal intermediary, no |
| 18 | | later than 180 days after the latest date on the claim on which |
| 19 | | medical goods or services were provided, with the following |
| 20 | | exceptions: |
| 21 | | (1) In the case of a provider whose enrollment is in |
| 22 | | process by the Illinois Department, the 180-day period |
| 23 | | shall not begin until the date on the written notice from |
| 24 | | the Illinois Department that the provider enrollment is |
| 25 | | complete. |
| 26 | | (2) In the case of errors attributable to the Illinois |
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| 1 | | Department or any of its claims processing intermediaries |
| 2 | | which result in an inability to receive, process, or |
| 3 | | adjudicate a claim, the 180-day period shall not begin |
| 4 | | until the provider has been notified of the error. |
| 5 | | (3) In the case of a provider for whom the Illinois |
| 6 | | Department initiates the monthly billing process. |
| 7 | | (4) In the case of a provider operated by a unit of |
| 8 | | local government with a population exceeding 3,000,000 |
| 9 | | when local government funds finance federal participation |
| 10 | | for claims payments. |
| 11 | | For claims for services rendered during a period for which |
| 12 | | a recipient received retroactive eligibility, claims must be |
| 13 | | filed within 180 days after the Department determines the |
| 14 | | applicant is eligible. For claims for which the Illinois |
| 15 | | Department is not the primary payer, claims must be submitted |
| 16 | | to the Illinois Department within 180 days after the final |
| 17 | | adjudication by the primary payer. |
| 18 | | In the case of long term care facilities, within 5 days of |
| 19 | | receipt by the facility of required prescreening information, |
| 20 | | data for new admissions shall be entered into the Medical |
| 21 | | Electronic Data Interchange (MEDI) or the Recipient |
| 22 | | Eligibility Verification (REV) System or successor system, and |
| 23 | | within 15 days of receipt by the facility of required |
| 24 | | prescreening information, admission documents shall be |
| 25 | | submitted through MEDI or REV or shall be submitted directly to |
| 26 | | the Department of Human Services using required admission |
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| 1 | | forms. Effective September
1, 2014, admission documents, |
| 2 | | including all prescreening
information, must be submitted |
| 3 | | through MEDI or REV. Confirmation numbers assigned to an |
| 4 | | accepted transaction shall be retained by a facility to verify |
| 5 | | timely submittal. Once an admission transaction has been |
| 6 | | completed, all resubmitted claims following prior rejection |
| 7 | | are subject to receipt no later than 180 days after the |
| 8 | | admission transaction has been completed. |
| 9 | | Claims that are not submitted and received in compliance |
| 10 | | with the foregoing requirements shall not be eligible for |
| 11 | | payment under the medical assistance program, and the State |
| 12 | | shall have no liability for payment of those claims. |
| 13 | | To the extent consistent with applicable information and |
| 14 | | privacy, security, and disclosure laws, State and federal |
| 15 | | agencies and departments shall provide the Illinois Department |
| 16 | | access to confidential and other information and data necessary |
| 17 | | to perform eligibility and payment verifications and other |
| 18 | | Illinois Department functions. This includes, but is not |
| 19 | | limited to: information pertaining to licensure; |
| 20 | | certification; earnings; immigration status; citizenship; wage |
| 21 | | reporting; unearned and earned income; pension income; |
| 22 | | employment; supplemental security income; social security |
| 23 | | numbers; National Provider Identifier (NPI) numbers; the |
| 24 | | National Practitioner Data Bank (NPDB); program and agency |
| 25 | | exclusions; taxpayer identification numbers; tax delinquency; |
| 26 | | corporate information; and death records. |
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| 1 | | The Illinois Department shall enter into agreements with |
| 2 | | State agencies and departments, and is authorized to enter into |
| 3 | | agreements with federal agencies and departments, under which |
| 4 | | such agencies and departments shall share data necessary for |
| 5 | | medical assistance program integrity functions and oversight. |
| 6 | | The Illinois Department shall develop, in cooperation with |
| 7 | | other State departments and agencies, and in compliance with |
| 8 | | applicable federal laws and regulations, appropriate and |
| 9 | | effective methods to share such data. At a minimum, and to the |
| 10 | | extent necessary to provide data sharing, the Illinois |
| 11 | | Department shall enter into agreements with State agencies and |
| 12 | | departments, and is authorized to enter into agreements with |
| 13 | | federal agencies and departments, including but not limited to: |
| 14 | | the Secretary of State; the Department of Revenue; the |
| 15 | | Department of Public Health; the Department of Human Services; |
| 16 | | and the Department of Financial and Professional Regulation. |
| 17 | | Beginning in fiscal year 2013, the Illinois Department |
| 18 | | shall set forth a request for information to identify the |
| 19 | | benefits of a pre-payment, post-adjudication, and post-edit |
| 20 | | claims system with the goals of streamlining claims processing |
| 21 | | and provider reimbursement, reducing the number of pending or |
| 22 | | rejected claims, and helping to ensure a more transparent |
| 23 | | adjudication process through the utilization of: (i) provider |
| 24 | | data verification and provider screening technology; and (ii) |
| 25 | | clinical code editing; and (iii) pre-pay, pre- or |
| 26 | | post-adjudicated predictive modeling with an integrated case |
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| 1 | | management system with link analysis. Such a request for |
| 2 | | information shall not be considered as a request for proposal |
| 3 | | or as an obligation on the part of the Illinois Department to |
| 4 | | take any action or acquire any products or services. |
| 5 | | The Illinois Department shall establish policies, |
| 6 | | procedures,
standards and criteria by rule for the acquisition, |
| 7 | | repair and replacement
of orthotic and prosthetic devices and |
| 8 | | durable medical equipment. Such
rules shall provide, but not be |
| 9 | | limited to, the following services: (1)
immediate repair or |
| 10 | | replacement of such devices by recipients; and (2) rental, |
| 11 | | lease, purchase or lease-purchase of
durable medical equipment |
| 12 | | in a cost-effective manner, taking into
consideration the |
| 13 | | recipient's medical prognosis, the extent of the
recipient's |
| 14 | | needs, and the requirements and costs for maintaining such
|
| 15 | | equipment. Subject to prior approval, such rules shall enable a |
| 16 | | recipient to temporarily acquire and
use alternative or |
| 17 | | substitute devices or equipment pending repairs or
|
| 18 | | replacements of any device or equipment previously authorized |
| 19 | | for such
recipient by the Department. Notwithstanding any |
| 20 | | provision of Section 5-5f to the contrary, the Department may, |
| 21 | | by rule, exempt certain replacement wheelchair parts from prior |
| 22 | | approval and, for wheelchairs, wheelchair parts, wheelchair |
| 23 | | accessories, and related seating and positioning items, |
| 24 | | determine the wholesale price by methods other than actual |
| 25 | | acquisition costs. |
| 26 | | The Department shall require, by rule, all providers of |
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| 1 | | durable medical equipment to be accredited by an accreditation |
| 2 | | organization approved by the federal Centers for Medicare and |
| 3 | | Medicaid Services and recognized by the Department in order to |
| 4 | | bill the Department for providing durable medical equipment to |
| 5 | | recipients. No later than 15 months after the effective date of |
| 6 | | the rule adopted pursuant to this paragraph, all providers must |
| 7 | | meet the accreditation requirement.
|
| 8 | | The Department shall execute, relative to the nursing home |
| 9 | | prescreening
project, written inter-agency agreements with the |
| 10 | | Department of Human
Services and the Department on Aging, to |
| 11 | | effect the following: (i) intake
procedures and common |
| 12 | | eligibility criteria for those persons who are receiving
|
| 13 | | non-institutional services; and (ii) the establishment and |
| 14 | | development of
non-institutional services in areas of the State |
| 15 | | where they are not currently
available or are undeveloped; and |
| 16 | | (iii) notwithstanding any other provision of law, subject to |
| 17 | | federal approval, on and after July 1, 2012, an increase in the |
| 18 | | determination of need (DON) scores from 29 to 37 for applicants |
| 19 | | for institutional and home and community-based long term care; |
| 20 | | if and only if federal approval is not granted, the Department |
| 21 | | may, in conjunction with other affected agencies, implement |
| 22 | | utilization controls or changes in benefit packages to |
| 23 | | effectuate a similar savings amount for this population; and |
| 24 | | (iv) no later than July 1, 2013, minimum level of care |
| 25 | | eligibility criteria for institutional and home and |
| 26 | | community-based long term care; and (v) no later than October |
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| 1 | | 1, 2013, establish procedures to permit long term care |
| 2 | | providers access to eligibility scores for individuals with an |
| 3 | | admission date who are seeking or receiving services from the |
| 4 | | long term care provider. In order to select the minimum level |
| 5 | | of care eligibility criteria, the Governor shall establish a |
| 6 | | workgroup that includes affected agency representatives and |
| 7 | | stakeholders representing the institutional and home and |
| 8 | | community-based long term care interests. This Section shall |
| 9 | | not restrict the Department from implementing lower level of |
| 10 | | care eligibility criteria for community-based services in |
| 11 | | circumstances where federal approval has been granted.
|
| 12 | | The Illinois Department shall develop and operate, in |
| 13 | | cooperation
with other State Departments and agencies and in |
| 14 | | compliance with
applicable federal laws and regulations, |
| 15 | | appropriate and effective
systems of health care evaluation and |
| 16 | | programs for monitoring of
utilization of health care services |
| 17 | | and facilities, as it affects
persons eligible for medical |
| 18 | | assistance under this Code.
|
| 19 | | The Illinois Department shall report annually to the |
| 20 | | General Assembly,
no later than the second Friday in April of |
| 21 | | 1979 and each year
thereafter, in regard to:
|
| 22 | | (a) actual statistics and trends in utilization of |
| 23 | | medical services by
public aid recipients;
|
| 24 | | (b) actual statistics and trends in the provision of |
| 25 | | the various medical
services by medical vendors;
|
| 26 | | (c) current rate structures and proposed changes in |
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| 1 | | those rate structures
for the various medical vendors; and
|
| 2 | | (d) efforts at utilization review and control by the |
| 3 | | Illinois Department.
|
| 4 | | The period covered by each report shall be the 3 years |
| 5 | | ending on the June
30 prior to the report. The report shall |
| 6 | | include suggested legislation
for consideration by the General |
| 7 | | Assembly. The filing of one copy of the
report with the |
| 8 | | Speaker, one copy with the Minority Leader and one copy
with |
| 9 | | the Clerk of the House of Representatives, one copy with the |
| 10 | | President,
one copy with the Minority Leader and one copy with |
| 11 | | the Secretary of the
Senate, one copy with the Legislative |
| 12 | | Research Unit, and such additional
copies
with the State |
| 13 | | Government Report Distribution Center for the General
Assembly |
| 14 | | as is required under paragraph (t) of Section 7 of the State
|
| 15 | | Library Act shall be deemed sufficient to comply with this |
| 16 | | Section.
|
| 17 | | Rulemaking authority to implement Public Act 95-1045, if |
| 18 | | any, is conditioned on the rules being adopted in accordance |
| 19 | | with all provisions of the Illinois Administrative Procedure |
| 20 | | Act and all rules and procedures of the Joint Committee on |
| 21 | | Administrative Rules; any purported rule not so adopted, for |
| 22 | | whatever reason, is unauthorized. |
| 23 | | On and after July 1, 2012, the Department shall reduce any |
| 24 | | rate of reimbursement for services or other payments or alter |
| 25 | | any methodologies authorized by this Code to reduce any rate of |
| 26 | | reimbursement for services or other payments in accordance with |
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| 1 | | Section 5-5e. |
| 2 | | Because kidney transplantation can be an appropriate, cost |
| 3 | | effective
alternative to renal dialysis when medically |
| 4 | | necessary and notwithstanding the provisions of Section 1-11 of |
| 5 | | this Code, beginning October 1, 2014, the Department shall |
| 6 | | cover kidney transplantation for noncitizens with end-stage |
| 7 | | renal disease who are not eligible for comprehensive medical |
| 8 | | benefits, who meet the residency requirements of Section 5-3 of |
| 9 | | this Code, and who would otherwise meet the financial |
| 10 | | requirements of the appropriate class of eligible persons under |
| 11 | | Section 5-2 of this Code. To qualify for coverage of kidney |
| 12 | | transplantation, such person must be receiving emergency renal |
| 13 | | dialysis services covered by the Department. Providers under |
| 14 | | this Section shall be prior approved and certified by the |
| 15 | | Department to perform kidney transplantation and the services |
| 16 | | under this Section shall be limited to services associated with |
| 17 | | kidney transplantation. |
| 18 | | Notwithstanding any other provision of this Code to the |
| 19 | | contrary, on or after July 1, 2015, all FDA approved forms of |
| 20 | | medication assisted treatment prescribed for the treatment of |
| 21 | | alcohol dependence or treatment of opioid dependence shall be |
| 22 | | covered under both fee for service and managed care medical |
| 23 | | assistance programs for persons who are otherwise eligible for |
| 24 | | medical assistance under this Article and shall not be subject |
| 25 | | to any (1) utilization control, other than those established |
| 26 | | under the American Society of Addiction Medicine patient |
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| 1 | | placement criteria,
(2) prior authorization mandate, or (3) |
| 2 | | lifetime restriction limit
mandate. |
| 3 | | On or after July 1, 2015, opioid antagonists prescribed for |
| 4 | | the treatment of an opioid overdose, including the medication |
| 5 | | product, administration devices, and any pharmacy fees related |
| 6 | | to the dispensing and administration of the opioid antagonist, |
| 7 | | shall be covered under the medical assistance program for |
| 8 | | persons who are otherwise eligible for medical assistance under |
| 9 | | this Article. As used in this Section, "opioid antagonist" |
| 10 | | means a drug that binds to opioid receptors and blocks or |
| 11 | | inhibits the effect of opioids acting on those receptors, |
| 12 | | including, but not limited to, naloxone hydrochloride or any |
| 13 | | other similarly acting drug approved by the U.S. Food and Drug |
| 14 | | Administration. |
| 15 | | Upon federal approval, the Department shall provide |
| 16 | | coverage and reimbursement for all drugs that are approved for |
| 17 | | marketing by the federal Food and Drug Administration and that |
| 18 | | are recommended by the federal Public Health Service or the |
| 19 | | United States Centers for Disease Control and Prevention for |
| 20 | | pre-exposure prophylaxis and related pre-exposure prophylaxis |
| 21 | | services, including, but not limited to, HIV and sexually |
| 22 | | transmitted infection screening, treatment for sexually |
| 23 | | transmitted infections, medical monitoring, assorted labs, and |
| 24 | | counseling to reduce the likelihood of HIV infection among |
| 25 | | individuals who are not infected with HIV but who are at high |
| 26 | | risk of HIV infection. |
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| 1 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; |
| 2 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. |
| 3 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, |
| 4 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; |
| 5 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section |
| 6 | | 20 of P.A. 99-588 for the effective date of P.A. 99-407); |
| 7 | | 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff. |
| 8 | | 7-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895, |
| 9 | | eff. 1-1-17; 100-538, eff. 1-1-18.)
|
| 10 | | (305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
|
| 11 | | (Text of Section before amendment by P.A. 100-538) |
| 12 | | Sec. 5-8. Practitioners. In supplying medical assistance, |
| 13 | | the Illinois
Department may provide for the legally authorized |
| 14 | | services of (i) persons
licensed under the Medical Practice Act |
| 15 | | of 1987, as amended, except as
hereafter in this Section |
| 16 | | stated, whether under a
general or limited license, (ii) |
| 17 | | persons licensed under the Nurse Practice Act as advanced |
| 18 | | practice nurses, regardless of whether or not the persons have |
| 19 | | written collaborative agreements, (iii) persons licensed or |
| 20 | | registered
under
other laws of this State to provide dental, |
| 21 | | medical, pharmaceutical,
optometric, podiatric, or nursing |
| 22 | | services, or other remedial care
recognized under State law, |
| 23 | | and (iv) persons licensed under other laws of
this State as a |
| 24 | | clinical social worker. The Department shall adopt rules, no |
| 25 | | later than 90 days after the effective date of this amendatory |
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| 1 | | Act of the 99th General Assembly, for the legally authorized |
| 2 | | services of persons licensed under other laws of this State as |
| 3 | | a clinical social worker.
The Department may not provide for |
| 4 | | legally
authorized services of any physician who has been |
| 5 | | convicted of having performed
an abortion procedure in a wilful |
| 6 | | and wanton manner on a woman who was not
pregnant at the time |
| 7 | | such abortion procedure was performed. The
utilization of the |
| 8 | | services of persons engaged in the treatment or care of
the |
| 9 | | sick, which persons are not required to be licensed or |
| 10 | | registered under
the laws of this State, is not prohibited by |
| 11 | | this Section.
|
| 12 | | (Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17.)
|
| 13 | | (Text of Section after amendment by P.A. 100-538) |
| 14 | | Sec. 5-8. Practitioners. In supplying medical assistance, |
| 15 | | the Illinois
Department may provide for the legally authorized |
| 16 | | services of (i) persons
licensed under the Medical Practice Act |
| 17 | | of 1987, as amended, except as
hereafter in this Section |
| 18 | | stated, whether under a
general or limited license, (ii) |
| 19 | | persons licensed under the Nurse Practice Act as advanced |
| 20 | | practice nurses, regardless of whether or not the persons have |
| 21 | | written collaborative agreements, (iii) persons licensed or |
| 22 | | registered
under
other laws of this State to provide dental, |
| 23 | | medical, pharmaceutical,
optometric, podiatric, or nursing |
| 24 | | services, or other remedial care
recognized under State law, |
| 25 | | and (iv) persons licensed under other laws of
this State as a |
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| 1 | | clinical social worker. The Department shall adopt rules, no |
| 2 | | later than 90 days after the effective date of this amendatory |
| 3 | | Act of the 99th General Assembly, for the legally authorized |
| 4 | | services of persons licensed under other laws of this State as |
| 5 | | a clinical social worker.
The Department may not provide for |
| 6 | | legally authorized services of any physician who has been |
| 7 | | convicted of having performed an abortion procedure in a |
| 8 | | willful and wanton manner on a woman who was not pregnant at |
| 9 | | the time such abortion procedure was performed. The
utilization |
| 10 | | of the services of persons engaged in the treatment or care of
|
| 11 | | the sick, which persons are not required to be licensed or |
| 12 | | registered under
the laws of this State, is not prohibited by |
| 13 | | this Section.
|
| 14 | | (Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17; |
| 15 | | 100-538, eff. 1-1-18.)
|
| 16 | | (305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
|
| 17 | | (Text of Section before amendment by P.A. 100-538)
|
| 18 | | Sec. 5-9. Choice of medical dispensers. Applicants and |
| 19 | | recipients shall
be entitled to free choice of those qualified |
| 20 | | practitioners, hospitals,
nursing homes, and other dispensers |
| 21 | | of medical services meeting the
requirements and complying with |
| 22 | | the rules and regulations of the Illinois
Department. However, |
| 23 | | the Director of Healthcare and Family Services may, after |
| 24 | | providing
reasonable notice and opportunity for hearing, deny, |
| 25 | | suspend or terminate
any otherwise qualified person, firm, |
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| 1 | | corporation, association, agency,
institution, or other legal |
| 2 | | entity, from participation as a vendor of goods
or services |
| 3 | | under the medical assistance program authorized by this Article
|
| 4 | | if the Director finds such vendor of medical services in |
| 5 | | violation of this
Act or the policy or rules and regulations |
| 6 | | issued pursuant to this Act. Any
physician who has been |
| 7 | | convicted of performing an abortion procedure in a
wilful and |
| 8 | | wanton manner upon a woman who was not pregnant at the time |
| 9 | | such
abortion procedure was performed shall be automatically |
| 10 | | removed from the
list of physicians qualified to participate as |
| 11 | | a vendor of medical services
under the medical assistance |
| 12 | | program authorized by this Article.
|
| 13 | | (Source: P.A. 95-331, eff. 8-21-07.)
|
| 14 | | (Text of Section after amendment by P.A. 100-538)
|
| 15 | | Sec. 5-9. Choice of medical dispensers. Applicants and |
| 16 | | recipients shall
be entitled to free choice of those qualified |
| 17 | | practitioners, hospitals,
nursing homes, and other dispensers |
| 18 | | of medical services meeting the
requirements and complying with |
| 19 | | the rules and regulations of the Illinois
Department. However, |
| 20 | | the Director of Healthcare and Family Services may, after |
| 21 | | providing
reasonable notice and opportunity for hearing, deny, |
| 22 | | suspend or terminate
any otherwise qualified person, firm, |
| 23 | | corporation, association, agency,
institution, or other legal |
| 24 | | entity, from participation as a vendor of goods
or services |
| 25 | | under the medical assistance program authorized by this Article
|
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| 1 | | if the Director finds such vendor of medical services in |
| 2 | | violation of this
Act or the policy or rules and regulations |
| 3 | | issued pursuant to this Act. Any physician who has been |
| 4 | | convicted of performing an abortion procedure in a willful and |
| 5 | | wanton manner upon a woman who was not pregnant at the time |
| 6 | | such abortion procedure was performed shall be automatically |
| 7 | | removed from the list of physicians qualified to participate as |
| 8 | | a vendor of medical services under the medical assistance |
| 9 | | program authorized by this Article.
|
| 10 | | (Source: P.A. 100-538, eff. 1-1-18.)
|
| 11 | | (305 ILCS 5/6-1) (from Ch. 23, par. 6-1)
|
| 12 | | (Text of Section before amendment by P.A. 100-538)
|
| 13 | | Sec. 6-1. Eligibility requirements. Financial aid in |
| 14 | | meeting basic
maintenance requirements shall be given under |
| 15 | | this Article to
or in behalf of persons who meet the |
| 16 | | eligibility conditions of Sections
6-1.1 through 6-1.10.
In |
| 17 | | addition, each unit of local government subject to this Article |
| 18 | | shall
provide persons receiving financial aid in meeting basic |
| 19 | | maintenance
requirements with financial aid for either (a) |
| 20 | | necessary treatment, care, and
supplies required because of |
| 21 | | illness or disability, or (b) acute medical
treatment, care, |
| 22 | | and supplies only. If a local governmental unit elects to
|
| 23 | | provide financial aid for acute medical treatment, care, and |
| 24 | | supplies only, the
general types of acute medical treatment, |
| 25 | | care, and supplies for which
financial
aid is provided shall be |
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| 1 | | specified in the general assistance rules of the local
|
| 2 | | governmental unit, which rules shall provide that financial aid |
| 3 | | is provided, at
a minimum, for acute medical treatment, care, |
| 4 | | or supplies necessitated by a
medical condition for which prior |
| 5 | | approval or authorization of medical
treatment, care, or |
| 6 | | supplies is not required by the general assistance rules
of the |
| 7 | | Illinois Department.
Nothing in this Article shall be construed
|
| 8 | | to permit the granting of financial aid where the purpose of |
| 9 | | such aid is to
obtain an abortion, induced miscarriage or |
| 10 | | induced premature birth
unless, in the opinion of a physician, |
| 11 | | such procedures are necessary for
the preservation of the life |
| 12 | | of the woman seeking such treatment, or
except an induced |
| 13 | | premature birth intended to produce a live viable
child and |
| 14 | | such procedure is necessary for the health of the mother or
her |
| 15 | | unborn child.
|
| 16 | | (Source: P.A. 92-111, eff. 1-1-02.)
|
| 17 | | (Text of Section after amendment by P.A. 100-538)
|
| 18 | | Sec. 6-1. Eligibility requirements. Financial aid in |
| 19 | | meeting basic
maintenance requirements shall be given under |
| 20 | | this Article to
or in behalf of persons who meet the |
| 21 | | eligibility conditions of Sections
6-1.1 through 6-1.10, |
| 22 | | except as provided in the No Taxpayer Funding for Abortion Act.
|
| 23 | | In addition, each unit of local government subject to this |
| 24 | | Article shall
provide persons receiving financial aid in |
| 25 | | meeting basic maintenance
requirements with financial aid for |
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| 1 | | either (a) necessary treatment, care, and
supplies required |
| 2 | | because of illness or disability, or (b) acute medical
|
| 3 | | treatment, care, and supplies only. If a local governmental |
| 4 | | unit elects to
provide financial aid for acute medical |
| 5 | | treatment, care, and supplies only, the
general types of acute |
| 6 | | medical treatment, care, and supplies for which
financial
aid |
| 7 | | is provided shall be specified in the general assistance rules |
| 8 | | of the local
governmental unit, which rules shall provide that |
| 9 | | financial aid is provided, at
a minimum, for acute medical |
| 10 | | treatment, care, or supplies necessitated by a
medical |
| 11 | | condition for which prior approval or authorization of medical
|
| 12 | | treatment, care, or supplies is not required by the general |
| 13 | | assistance rules
of the Illinois Department.
|
| 14 | | (Source: P.A. 100-538, eff. 1-1-18.)
|
| 15 | | Section 910. The Problem Pregnancy Health Services and Care |
| 16 | | Act is amended by changing Section 4-100 as follows:
|
| 17 | | (410 ILCS 230/4-100) (from Ch. 111 1/2, par. 4604-100)
|
| 18 | | (Text of Section before amendment by P.A. 100-538)
|
| 19 | | Sec. 4-100.
The Department may make grants to nonprofit |
| 20 | | agencies and organizations
which do not use such grants to |
| 21 | | refer or counsel for, or perform, abortions
and which |
| 22 | | coordinate and establish linkages among services that will |
| 23 | | further
the purposes of this Act and, where appropriate, will |
| 24 | | provide,
supplement, or improve the quality of such services.
|
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| 1 | | (Source: P.A. 83-51.)
|
| 2 | | (Text of Section after amendment by P.A. 100-538)
|
| 3 | | Sec. 4-100.
The Department may make grants to nonprofit |
| 4 | | agencies and organizations which do not use such grants to |
| 5 | | refer or counsel for, or perform, abortions and
which |
| 6 | | coordinate and establish linkages among services that will |
| 7 | | further
the purposes of this Act and, where appropriate, will |
| 8 | | provide,
supplement, or improve the quality of such services.
|
| 9 | | (Source: P.A. 100-538, eff. 1-1-18.)
|
| 10 | | Section 990. Application of Act; home rule powers.
|
| 11 | | (a) This Act applies to all State and local (including home |
| 12 | | rule unit) laws, ordinances, policies, procedures, practices, |
| 13 | | and governmental actions and their implementation, whether |
| 14 | | statutory or otherwise and whether adopted before or after the |
| 15 | | effective date of this Act.
|
| 16 | | (b) A home rule unit may not adopt any rule in a manner |
| 17 | | inconsistent with this Act. This Act is a limitation under |
| 18 | | subsection (i) of Section 6 of Article VII of the Illinois |
| 19 | | Constitution on the concurrent exercise by home rule units of |
| 20 | | powers and functions exercised by the State.
|
| 21 | | Section 995. No acceleration or delay. Where this Act makes |
| 22 | | changes in a statute that is represented in this Act by text |
| 23 | | that is not yet or no longer in effect (for example, a Section |