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| | 99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB4341 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
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| New Act | | 5 ILCS 80/4.37 new | | 225 ILCS 60/4 | from Ch. 111, par. 4400-4 | 225 ILCS 65/50-15 | was 225 ILCS 65/5-15 | 305 ILCS 5/5-5 | from Ch. 23, par. 5-5 |
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Creates the Home Birth Safety Act. Provides for the licensure of midwives by the Department of Financial and Professional Regulation. Creates the Illinois Midwifery Board. Sets forth provisions concerning qualifications, grounds for disciplinary action, and administrative procedures. Amends the Regulatory Sunset Act to set a repeal date for the new Act of January 1, 2027. Amends the Medical Practice Act of 1987, the Nurse Practice Act, and the Illinois Public Aid Code to make related changes. Effective July 1, 2016.
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| | | CORRECTIONAL BUDGET AND IMPACT NOTE ACT MAY APPLY | FISCAL NOTE ACT MAY APPLY | HOME RULE NOTE ACT MAY APPLY |
| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
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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 Home |
| 5 | | Birth Safety Act.
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| 6 | | Section 5. Purpose. The practice of midwifery in |
| 7 | | out-of-hospital settings is hereby declared to affect the |
| 8 | | public health, safety, and welfare and to be subject to |
| 9 | | regulation in the public interest. The purpose of this Act is |
| 10 | | to protect and benefit the public by setting standards for the |
| 11 | | qualifications, education, training, and experience of those |
| 12 | | who seek to obtain licensure and hold the title of licensed |
| 13 | | midwife, to promote high standards of professional performance |
| 14 | | for those licensed to practice midwifery in out-of-hospital |
| 15 | | settings in this State, and to protect the public from |
| 16 | | unprofessional conduct by persons licensed to practice |
| 17 | | midwifery, as defined in this Act. This Act shall be liberally |
| 18 | | construed to best carry out these purposes.
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| 19 | | Section 10. Exemptions. |
| 20 | | (a) This Act does not prohibit a person licensed under any |
| 21 | | other Act in this State from engaging in the practice for which |
| 22 | | he or she is licensed or from delegating services as provided |
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| 1 | | for under that other Act. |
| 2 | | (b) Nothing in this Act shall be construed to prohibit or |
| 3 | | require licensing under this Act, with regard to: |
| 4 | | (1) the gratuitous rendering of services; |
| 5 | | (2) the rendering of services by a person, if such |
| 6 | | attendance is in accordance with the person's religious |
| 7 | | faith and is rendered to persons with a similar religious |
| 8 | | faith as an exercise and enjoyment of their religious |
| 9 | | freedom; and |
| 10 | | (3) a student midwife working under the direction of a |
| 11 | | licensed midwife. |
| 12 | | (c) Nothing in this Act abridges, limits, or changes in any |
| 13 | | way the right of parents to deliver their baby where, when, |
| 14 | | how, and with whom they choose, regardless of licensure under |
| 15 | | this Act.
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| 16 | | Section 15. Definitions. In this Act:
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| 17 | | "Board" means the Illinois Midwifery Board. |
| 18 | | "Certified professional midwife" or "CPM" means a person |
| 19 | | who has met the standards for certification set by the North |
| 20 | | American Registry of Midwives and has been awarded the |
| 21 | | Certified Professional Midwife credential. |
| 22 | | "Department" means the Department of Financial and |
| 23 | | Professional Regulation. |
| 24 | | "International Confederation of Midwives" means the |
| 25 | | organization that sets global standards for the education and |
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| 1 | | autonomous practice of midwifery. |
| 2 | | "Licensed midwife" means a person who has been granted a |
| 3 | | license under this Act to engage in the practice of midwifery. |
| 4 | | "Midwifery Bridge Certificate" means the certificate |
| 5 | | issued by NARM based upon completion of accredited continuing |
| 6 | | education specific to content in emergency skills for |
| 7 | | pregnancy, birth, and newborn care, along with other midwifery |
| 8 | | topics addressing the core competencies of the International |
| 9 | | Confederation of Midwives. |
| 10 | | "Midwifery Education and Accreditation Council" or "MEAC" |
| 11 | | means the nationally-recognized accrediting agency that |
| 12 | | establishes standards for the education of direct-entry |
| 13 | | midwifery in the United States. |
| 14 | | "National Association of Certified Professional Midwives" |
| 15 | | means the professional organization, or its successor, that |
| 16 | | promotes the growth and development of the profession of |
| 17 | | certified professional midwives. |
| 18 | | "North American Registry of Midwives" or "NARM" means the |
| 19 | | accredited international agency, or its successor, that has |
| 20 | | established and has continued to administer certification for |
| 21 | | the credentialing of certified professional midwives. |
| 22 | | "Practice of midwifery" means providing the necessary |
| 23 | | supervision, care, education, and advice to pregnant people |
| 24 | | during the antepartum, intrapartum, and postpartum period, |
| 25 | | conducting deliveries independently, and caring for the |
| 26 | | newborn, with such care including without limitation |
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| 1 | | preventative measures, the detection of abnormal conditions in |
| 2 | | the mother and the child, the procurement of medical |
| 3 | | assistance, and the execution of emergency measures in the |
| 4 | | absence of medical help. "Practice of midwifery" includes |
| 5 | | non-prescriptive family planning and basic well-woman care. |
| 6 | | "Secretary" means the Secretary of Financial and |
| 7 | | Professional Regulation.
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| 8 | | Section 20. Unlicensed practice. Beginning January 1, |
| 9 | | 2017, no person may practice, attempt to practice, or hold |
| 10 | | himself or herself out to practice as a licensed midwife unless |
| 11 | | he or she is licensed as a midwife under this Act.
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| 12 | | Section 25. Title.
A licensed midwife may identify himself |
| 13 | | or herself as a "licensed midwife" and may use the abbreviation |
| 14 | | L.M.
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| 15 | | Section 30. Informed consent. |
| 16 | | (a) A licensed midwife shall, at an initial consultation |
| 17 | | with a client, provide a copy of the rules under this Act and |
| 18 | | disclose to the client orally and in writing all of the |
| 19 | | following: |
| 20 | | (1) The licensed midwife's experience and training. |
| 21 | | (2) Whether the licensed midwife has malpractice |
| 22 | | liability insurance coverage and the policy limits of any |
| 23 | | such coverage. |
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| 1 | | (3) A written protocol for the handling of medical |
| 2 | | emergencies, including transportation to a hospital, |
| 3 | | particular to each client. |
| 4 | | (b) A copy of the informed consent document, signed and |
| 5 | | dated by the client, must be kept in each client's chart.
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| 6 | | Section 33. Vicarious liability. No physician licensed to |
| 7 | | practice medicine in all its branches or advanced practice |
| 8 | | nurse shall be held liable for an injury solely resulting from |
| 9 | | an act or omission by a licensed midwife.
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| 10 | | Except as may otherwise be provided by law, nothing in this |
| 11 | | Section shall exempt any physician licensed to practice |
| 12 | | medicine in all its branches or advanced practice nurse from |
| 13 | | liability for his or her own negligent, grossly negligent, or |
| 14 | | willful or wanton acts or omissions.
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| 15 | | Section 35. Advertising. |
| 16 | | (a) Any person licensed under this Act may advertise the |
| 17 | | availability of professional midwifery services in the public |
| 18 | | media or on premises where professional services are rendered, |
| 19 | | if the advertising is truthful and not misleading and is in |
| 20 | | conformity with any rules regarding the practice of a licensed |
| 21 | | midwife.
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| 22 | | (b) A licensee must include in every advertisement for |
| 23 | | midwifery services regulated under this Act his or her title as |
| 24 | | it appears on the license or the initials authorized under this |
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| 1 | | Act.
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| 2 | | Section 40. Powers and duties of the Department; rules. |
| 3 | | (a) The Department shall exercise the powers and duties |
| 4 | | prescribed by the Civil Administrative Code of Illinois for the |
| 5 | | administration of licensing Acts and shall exercise such other |
| 6 | | powers and duties necessary for effectuating the purposes of |
| 7 | | this Act. |
| 8 | | (b) The Secretary shall adopt rules consistent with the |
| 9 | | provisions of this Act for the administration and enforcement |
| 10 | | of the Act and for the payment of fees connected to the Act and |
| 11 | | may prescribe forms that shall be issued in connection with the |
| 12 | | Act. |
| 13 | | (c) Rules adopted by the Department must provide for the |
| 14 | | following: |
| 15 | | (1) The scope of practice and services provided and the |
| 16 | | use of equipment, procedures, and medications, including |
| 17 | | the creation of a formulary of allowable drugs and |
| 18 | | procedures for use by a licensed midwife which are |
| 19 | | determined by the Department to be necessarily available in |
| 20 | | order to assure the health and safety of the mother and |
| 21 | | newborn and are in keeping with current midwifery |
| 22 | | standards. All rules for equipment, procedures, and |
| 23 | | medications may be updated as the Department deems |
| 24 | | necessary to be in keeping with changing standards. |
| 25 | | (2) The issuance of temporary licenses to practice |
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| 1 | | midwifery pending qualification for licensure.
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| 2 | | (d) The rules adopted by the Department under this Section |
| 3 | | may not: |
| 4 | | (1) require a licensed midwife to practice midwifery |
| 5 | | under the supervision of another health care provider; |
| 6 | | (2) require a licensed midwife to enter into a written |
| 7 | | agreement with another health care provider; |
| 8 | | (3) limit the location where a licensed midwife may |
| 9 | | practice midwifery; or |
| 10 | | (4) permit a licensed midwife to do any of the |
| 11 | | following: |
| 12 | | (A) administer prescription pharmacological agents |
| 13 | | intended to induce or augment labor; |
| 14 | | (B) administer prescription pharmacological agents |
| 15 | | to provide pain management; |
| 16 | | (C) use vacuum extractors or forceps; |
| 17 | | (D) prescribe medications; or |
| 18 | | (E) perform major surgical procedures, including, |
| 19 | | but not limited to, abortions, caesarean sections, and |
| 20 | | circumcisions.
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| 21 | | (e) With regards to Medicaid reimbursement, no rules |
| 22 | | prescribed by the Department shall require the licensed midwife |
| 23 | | to carry liability insurance in order to be reimbursed by the |
| 24 | | State as a Medicaid provider. |
| 25 | | (f) The Department shall consult with the Board in adopting |
| 26 | | rules. Notice of proposed rulemaking shall be transmitted to |
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| 1 | | the Board and the Department shall review the Board's response |
| 2 | | and any recommendations made. The Department shall notify the |
| 3 | | Board in writing with proper explanation of deviations from the |
| 4 | | Board's recommendations and responses. |
| 5 | | (g) The Department may at any time seek the advice and the |
| 6 | | expert knowledge of the Board on any matter relating to the |
| 7 | | administration of this Act. |
| 8 | | (h) The Department shall issue quarterly a report to the |
| 9 | | Board of the status of all complaints related to the profession |
| 10 | | filed with the Department. |
| 11 | | (i) Administration by the Department of this Act must be |
| 12 | | consistent with standards regarding the practice of midwifery |
| 13 | | established by the National Association of Certified |
| 14 | | Professional Midwives or a successor organization whose |
| 15 | | essential documents include without limitation subject matter |
| 16 | | concerning scope of practice, standards of practice, informed |
| 17 | | consent, appropriate consultation, collaboration or referral,
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| 18 | | and acknowledgement of a woman's right to self-determination |
| 19 | | concerning her maternity care.
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| 20 | | Section 45. Illinois Midwifery Board.
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| 21 | | (a) There is created under the authority of the Department |
| 22 | | the Illinois Midwifery Board, which shall consist of 5 members |
| 23 | | appointed by the Secretary, 3 of whom shall be licensed |
| 24 | | midwives who carry the CPM credential, except that initial |
| 25 | | appointees must have at least 3 years of experience in the |
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| 1 | | practice of midwifery in an out-of-hospital setting, be |
| 2 | | certified by the North American Registry of Midwives, and meet |
| 3 | | the qualifications for licensure set forth in this Act; one of |
| 4 | | whom shall be a licensed obstetrician or a family practice |
| 5 | | physician or certified nurse midwife who has a minimum of 2 |
| 6 | | years of experience providing home birth services; and one of |
| 7 | | whom shall be a knowledgeable public member who has given birth |
| 8 | | with the assistance of a certified professional midwife in an |
| 9 | | out-of-hospital birth setting. A physician or certified nurse |
| 10 | | midwife who has a minimum of 2 years' experience consulting or |
| 11 | | collaborating with a home birth provider may stand in |
| 12 | | substitution if the criteria for physician or certified nurse |
| 13 | | midwife Board members cannot be met. Board members shall serve |
| 14 | | 4-year terms, except that in the case of initial appointments, |
| 15 | | terms shall be staggered as follows: 3 members shall serve for |
| 16 | | 4 years, and 2 members shall serve for 2 years. The Board shall |
| 17 | | annually elect a chairperson and vice chairperson. |
| 18 | | (b) Any appointment made to fill a vacancy shall be for the |
| 19 | | unexpired portion of the term. Appointments to fill vacancies |
| 20 | | shall be made in the same manner as original appointments. No |
| 21 | | Board member may be reappointed for a term that would cause his |
| 22 | | or her continuous service on the Board to exceed 9 years. |
| 23 | | (c) Board membership must have reasonable representation |
| 24 | | from different geographic areas of this State. |
| 25 | | (d) The members of the Board may be reimbursed for all |
| 26 | | legitimate, necessary, and authorized expenses incurred in |
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| 1 | | attending the meetings of the Board.
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| 2 | | (e) The Secretary may remove any member of the Board for |
| 3 | | misconduct, incapacity, or neglect of duty at any time prior to |
| 4 | | the expiration of his or her term.
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| 5 | | (f) Three Board members shall constitute a quorum. A |
| 6 | | vacancy in the membership of the Board shall not impair the |
| 7 | | right of a quorum to perform all of the duties of the Board.
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| 8 | | (g) The Board shall provide the Department with |
| 9 | | recommendations concerning the administration of this Act and |
| 10 | | may perform each of the following duties: |
| 11 | | (1) Recommend to the Department the prescription and, |
| 12 | | from time to time, the revision of any rules that may be |
| 13 | | necessary to carry out the provisions of this Act, |
| 14 | | including those that are designed to protect the health, |
| 15 | | safety, and welfare of the public. |
| 16 | | (2) Conduct hearings and disciplinary conferences on |
| 17 | | disciplinary charges of licensees. |
| 18 | | (3) Report to the Department, upon completion of a |
| 19 | | hearing, the disciplinary actions recommended to be taken |
| 20 | | against a person found in violation of this Act.
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| 21 | | (4) Recommend the approval, denial of approval, and |
| 22 | | withdrawal of approval of required education and |
| 23 | | continuing educational programs.
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| 24 | | (h) The Secretary shall give due consideration to all |
| 25 | | recommendations of the Board. If the Secretary takes action |
| 26 | | contrary to a recommendation of the Board, the Secretary must |
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| 1 | | promptly provide a written explanation of that action. |
| 2 | | (i) The Board may recommend to the Secretary that one or |
| 3 | | more licensed midwives be selected by the Secretary to assist |
| 4 | | in any investigation under this Act. Compensation shall be |
| 5 | | provided to any licensee who provides assistance under this |
| 6 | | subsection (i), in an amount determined by the Secretary.
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| 7 | | (j) Members of the Board shall be immune from suit in an |
| 8 | | action based upon a disciplinary proceeding or other activity |
| 9 | | performed in good faith as a member of the Board, except for |
| 10 | | willful or wanton misconduct.
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| 11 | | (k) Members of the Board may participate in and act at any |
| 12 | | meeting of the Illinois Midwifery Board through the use of any |
| 13 | | real-time internet or telephone communication media, by means |
| 14 | | of which all persons participating in the meeting can |
| 15 | | communicate with each other. Participation in such meeting |
| 16 | | shall constitute attendance and presence in person at the |
| 17 | | meeting of the person or persons so participating.
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| 18 | | Section 50. Qualifications. |
| 19 | | (a) A person is qualified for licensure as a midwife if he |
| 20 | | or she has received certification and holds a valid CPM |
| 21 | | credential granted by NARM. In addition to earning his or her |
| 22 | | CPM credential: (1) a CPM certified before January 1, 2020 who |
| 23 | | has obtained certification through an educational pathway not |
| 24 | | accredited by MEAC must earn and submit a Midwifery Bridge |
| 25 | | Certificate issued by NARM or (2) a CPM certified after January |
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| 1 | | 1, 2020 must have completed an educational program or pathway |
| 2 | | accredited by MEAC. |
| 3 | | (b) A CPM who has maintained licensure in a state that does |
| 4 | | not require an accredited education shall submit a Midwifery |
| 5 | | Bridge Certificate regardless of the date of their |
| 6 | | certification. |
| 7 | | (c) An applicant for licensure who is a CPM applying in the |
| 8 | | first 3 months that licensure is available shall be issued a |
| 9 | | temporary license and shall have 18 months to earn and submit a |
| 10 | | completed Midwifery Bridge Certificate.
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| 11 | | Section 55. Social Security Number on application. In |
| 12 | | addition to any other information required to be contained in |
| 13 | | the application, every application for an original, renewal, |
| 14 | | reinstated, or restored license under this Act shall include |
| 15 | | the applicant's Social Security Number.
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| 16 | | Section 60. Renewal of licensure. |
| 17 | | (a) Licensed midwives shall renew their license biannually |
| 18 | | at the discretion of the Department. |
| 19 | | (b) Rules adopted under this Act shall require the licensed |
| 20 | | midwife to maintain CPM certification by meeting all the |
| 21 | | continuing education requirements and other requirements set |
| 22 | | forth by the North American Registry of Midwives.
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| 23 | | Section 65. Inactive status. |
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| 1 | | (a) A licensed midwife who notifies the Department in |
| 2 | | writing on forms prescribed by the Department may elect to |
| 3 | | place his or her license on an inactive status and shall be |
| 4 | | excused from payment of renewal fees until he or she notifies |
| 5 | | the Department in writing of his or her intent to restore the |
| 6 | | license.
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| 7 | | (b) A licensed midwife whose license is on inactive status |
| 8 | | may not practice licensed midwifery in the State of Illinois.
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| 9 | | (c) A licensed midwife requesting restoration from |
| 10 | | inactive status shall be required to pay the current renewal |
| 11 | | fee and to restore his or her license, as provided by the |
| 12 | | Department.
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| 13 | | (d) Any licensee who engages in the practice of midwifery |
| 14 | | while his or her license is lapsed or on inactive status shall |
| 15 | | be considered to be practicing without a license, which shall |
| 16 | | be grounds for discipline.
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| 17 | | Section 70. Renewal, reinstatement, or restoration of |
| 18 | | licensure; military service. |
| 19 | | (a) The expiration date and renewal period for each license |
| 20 | | issued under this Act shall be set by the Department.
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| 21 | | (b) All renewal applicants shall provide proof of having |
| 22 | | maintained CPM certification by meeting continuing education |
| 23 | | requirements and other requirements set forth by the North |
| 24 | | American Registry of Midwives. |
| 25 | | (c) Any licensed midwife who has permitted his or her |
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| 1 | | license to expire or who has had his or her license on inactive |
| 2 | | status may have his or her license restored by making |
| 3 | | application to the Department and filing proof acceptable to |
| 4 | | the Department of fitness to have the license restored and by |
| 5 | | paying the required fees. Proof of fitness may include evidence |
| 6 | | attesting to active lawful practice in another jurisdiction.
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| 7 | | (d) The Department shall determine, by an evaluation |
| 8 | | program, fitness for restoration of a license under this |
| 9 | | Section and shall establish procedures and requirements for |
| 10 | | restoration.
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| 11 | | (e) Any licensed midwife whose license expired while he or |
| 12 | | she was (i) in federal service on active duty with the Armed |
| 13 | | Forces of the United States or the State Militia and called |
| 14 | | into service or training or (ii) received education under the |
| 15 | | supervision of the United States preliminary to induction into |
| 16 | | the military service may have his or her license restored |
| 17 | | without paying any lapsed renewal fees, if, within 2 years |
| 18 | | after honorable termination of service, training, or |
| 19 | | education, he or she furnishes the Department with satisfactory |
| 20 | | evidence to the effect that he or she has been so engaged.
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| 21 | | Section 75. Roster. The Department shall maintain a roster |
| 22 | | of the names and addresses of all licensees and of all persons |
| 23 | | whose licenses have been suspended or revoked. This roster |
| 24 | | shall be available upon written request and payment of the |
| 25 | | required fee.
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| 1 | | Section 80. Fees. |
| 2 | | (a) The Department shall provide for a schedule of fees for |
| 3 | | the administration and enforcement of this Act, including |
| 4 | | without limitation original licensure, renewal, and |
| 5 | | restoration, which fees shall be nonrefundable.
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| 6 | | (b) All fees collected under this Act shall be deposited |
| 7 | | into the General Professions Dedicated Fund and appropriated to |
| 8 | | the Department for the ordinary and contingent expenses of the |
| 9 | | Department in the administration of this Act.
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| 10 | | Section 85. Returned checks; fines. Any person who delivers |
| 11 | | a check or other payment to the Department that is returned to |
| 12 | | the Department unpaid by the financial institution upon which |
| 13 | | it is drawn shall pay to the Department, in addition to the |
| 14 | | amount already owed to the Department, a fine of $50. The fines |
| 15 | | imposed by this Section are in addition to any other discipline |
| 16 | | provided under this Act for unlicensed practice or practice on |
| 17 | | a non-renewed license. The Department shall notify the person |
| 18 | | that fees and fines shall be paid to the Department by |
| 19 | | certified check or money order within 30 calendar days after |
| 20 | | the notification. If, after the expiration of 30 days from the |
| 21 | | date of the notification, the person has failed to submit the |
| 22 | | necessary remittance, the Department shall automatically |
| 23 | | terminate the license or deny the application, without hearing. |
| 24 | | If, after termination or denial, the person seeks a license, he |
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| 1 | | or she shall apply to the Department for restoration or |
| 2 | | issuance of the license and pay all fees and fines due to the |
| 3 | | Department. The Department may establish a fee for the |
| 4 | | processing of an application for restoration of a license to |
| 5 | | defray all expenses of processing the application. The |
| 6 | | Secretary may waive the fines due under this Section in |
| 7 | | individual cases where the Secretary finds that the fines would |
| 8 | | be unreasonable or unnecessarily burdensome.
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| 9 | | Section 90. Unlicensed practice; civil penalty. Any person |
| 10 | | who practices, offers to practice, attempts to practice, or |
| 11 | | holds himself or herself out to practice midwifery or as a |
| 12 | | midwife without being licensed under this Act shall, in |
| 13 | | addition to any other penalty provided by law, pay a civil |
| 14 | | penalty to the Department in an amount not to exceed $5,000 for |
| 15 | | each offense, as determined by the Department. The civil |
| 16 | | penalty shall be assessed by the Department after a hearing is |
| 17 | | held in accordance with the provisions set forth in this Act |
| 18 | | regarding the provision of a hearing for the discipline of a |
| 19 | | licensee.
The civil penalty shall be paid within 60 days after |
| 20 | | the effective date of the order imposing the civil penalty. The |
| 21 | | order shall constitute a judgment and may be filed and |
| 22 | | execution had thereon in the same manner as any judgment from |
| 23 | | any court of record.
The Department may investigate any |
| 24 | | unlicensed activity.
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| 1 | | Section 95. Grounds for disciplinary action. |
| 2 | | (a) The Department may refuse to issue or to renew or may |
| 3 | | revoke, suspend, place on probation, reprimand or take other |
| 4 | | disciplinary action as the Department may deem proper, |
| 5 | | including fines not to exceed $5,000 for each violation, with |
| 6 | | regard to any licensee or license for any one or combination of |
| 7 | | the following causes: |
| 8 | | (1) Violations of this Act or its rules.
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| 9 | | (2) Material misstatement in furnishing information to |
| 10 | | the Department.
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| 11 | | (3) Conviction of any crime under the laws of any U.S. |
| 12 | | jurisdiction that is (i) a felony, (ii) a misdemeanor, an |
| 13 | | essential element of which is dishonesty, or (iii) directly |
| 14 | | related to the practice of the profession.
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| 15 | | (4) Making any misrepresentation for the purpose of |
| 16 | | obtaining a license.
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| 17 | | (5) Professional incompetence or gross negligence.
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| 18 | | (6) Gross malpractice.
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| 19 | | (7) Aiding or assisting another person in violating any |
| 20 | | provision of this Act or its rules.
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| 21 | | (8) Failing to provide information within 60 days in |
| 22 | | response to a written request made by the Department.
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| 23 | | (9) Engaging in dishonorable, unethical, or |
| 24 | | unprofessional conduct of a character likely to deceive, |
| 25 | | defraud, or harm the public.
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| 26 | | (10) Habitual or excessive use or addiction to alcohol, |
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| 1 | | narcotics, stimulants, or any other chemical agent or drug |
| 2 | | that results in the inability to practice with reasonable |
| 3 | | judgment, skill, or safety.
|
| 4 | | (11) Discipline by another U.S. jurisdiction or |
| 5 | | foreign nation if at least one of the grounds for the |
| 6 | | discipline is the same or substantially equivalent to those |
| 7 | | set forth in this Act.
|
| 8 | | (12) Directly or indirectly giving to or receiving from |
| 9 | | any person, firm, corporation, partnership, or association |
| 10 | | any fee, commission, rebate, or other form of compensation |
| 11 | | for any professional services not actually or personally |
| 12 | | rendered. This shall not be deemed to include rent or other |
| 13 | | remunerations paid to an individual, partnership, or |
| 14 | | corporation by a licensed midwife for the lease, rental, or |
| 15 | | use of space, owned or controlled by the individual, |
| 16 | | partnership, corporation, or association.
|
| 17 | | (13) A finding by the Department that the licensee, |
| 18 | | after having his or her license placed on probationary |
| 19 | | status, has violated the terms of probation.
|
| 20 | | (14) Abandonment of a patient without cause.
|
| 21 | | (15) Willfully making or filing false records or |
| 22 | | reports relating to a licensee's practice, including, but |
| 23 | | not limited to, false records filed with State agencies or |
| 24 | | departments.
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| 25 | | (16) Physical illness or mental illness, including, |
| 26 | | but not limited to, deterioration through the aging process |
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| 1 | | or loss of motor skill that results in the inability to |
| 2 | | practice the profession with reasonable judgment, skill, |
| 3 | | or safety.
|
| 4 | | (17) Failure to provide a patient with a copy of his or |
| 5 | | her record upon the written request of the patient.
|
| 6 | | (18) Conviction by any court of competent |
| 7 | | jurisdiction, either within or without this State, of any |
| 8 | | violation of any law governing the practice of licensed |
| 9 | | midwifery or conviction in this or another state of any |
| 10 | | crime that is a felony under the laws of this State or |
| 11 | | conviction of a felony in a federal court, if the |
| 12 | | Department determines, after investigation, that the |
| 13 | | person has not been sufficiently rehabilitated to warrant |
| 14 | | the public trust.
|
| 15 | | (19) A finding that licensure has been applied for or |
| 16 | | obtained by fraudulent means.
|
| 17 | | (20) Being named as a perpetrator in an indicated |
| 18 | | report by the Department of Healthcare and Family Services |
| 19 | | under the Abused and Neglected Child Reporting Act and upon |
| 20 | | proof by clear and convincing evidence that the licensee |
| 21 | | has caused a child to be an abused child or a neglected |
| 22 | | child, as defined in the Abused and Neglected Child |
| 23 | | Reporting Act.
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| 24 | | (21) Practicing or attempting to practice under a name |
| 25 | | other than the full name shown on a license issued under |
| 26 | | this Act.
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| 1 | | (22) Immoral conduct in the commission of any act, such |
| 2 | | as sexual abuse, sexual misconduct, or sexual |
| 3 | | exploitation, related to the licensee's practice.
|
| 4 | | (23) Maintaining a professional relationship with any |
| 5 | | person, firm, or corporation when the licensed midwife |
| 6 | | knows or should know that a person, firm, or corporation is |
| 7 | | violating this Act.
|
| 8 | | (24) Failure to provide satisfactory proof of having |
| 9 | | participated in approved continuing education programs as |
| 10 | | determined by the Board and approved by the Secretary. |
| 11 | | Exceptions for extreme hardships are to be defined by the |
| 12 | | Department.
|
| 13 | | (b) The Department may refuse to issue or may suspend the |
| 14 | | license of any person who fails to (i) file a tax return or to |
| 15 | | pay the tax, penalty, or interest shown in a filed return or |
| 16 | | (ii) pay any final assessment of the tax, penalty, or interest, |
| 17 | | as required by any tax Act administered by the Illinois |
| 18 | | Department of Revenue, until the time that the requirements of |
| 19 | | that tax Act are satisfied.
|
| 20 | | (c) The determination by a circuit court that a licensee is |
| 21 | | subject to involuntary admission or judicial admission as |
| 22 | | provided in the Mental Health and Developmental Disabilities |
| 23 | | Code operates as an automatic suspension. The suspension shall |
| 24 | | end only upon a finding by a court that the patient is no |
| 25 | | longer subject to involuntary admission or judicial admission, |
| 26 | | the issuance of an order so finding and discharging the |
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| 1 | | patient, and the recommendation of the Board to the Secretary |
| 2 | | that the licensee be allowed to resume his or her practice.
|
| 3 | | (d) In enforcing this Section, the Department, upon a |
| 4 | | showing of a possible violation, may compel any person licensed |
| 5 | | to practice under this Act or who has applied for licensure or |
| 6 | | certification pursuant to this Act to submit to a mental or |
| 7 | | physical examination, or both, as required by and at the |
| 8 | | expense of the Department. The examining physicians shall be |
| 9 | | those specifically designated by the Department. The |
| 10 | | Department may order an examining physician to present |
| 11 | | testimony concerning the mental or physical examination of the |
| 12 | | licensee or applicant. No information shall be excluded by |
| 13 | | reason of any common law or statutory privilege relating to |
| 14 | | communications between the licensee or applicant and the |
| 15 | | examining physician. The person to be examined may have, at his |
| 16 | | or her own expense, another physician of his or her choice |
| 17 | | present during all aspects of the examination. Failure of any |
| 18 | | person to submit to a mental or physical examination when |
| 19 | | directed shall be grounds for suspension of a license until the |
| 20 | | person submits to the examination if the Department finds, |
| 21 | | after notice and hearing, that the refusal to submit to the |
| 22 | | examination was without reasonable cause.
|
| 23 | | If the Department finds an individual unable to practice |
| 24 | | because of the reasons set forth in this subsection (d), the |
| 25 | | Department may require that individual to submit to care, |
| 26 | | counseling, or treatment by physicians approved or designated |
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| 1 | | by the Department, as a condition, term, or restriction for |
| 2 | | continued, reinstated, or renewed licensure to practice or, in |
| 3 | | lieu of care, counseling, or treatment, the Department may file |
| 4 | | a complaint to immediately suspend, revoke, or otherwise |
| 5 | | discipline the license of the individual.
Any person whose |
| 6 | | license was granted, reinstated, renewed, disciplined, or |
| 7 | | supervised subject to such terms, conditions, or restrictions |
| 8 | | and who fails to comply with such terms, conditions, or |
| 9 | | restrictions shall be referred to the Secretary for a |
| 10 | | determination as to whether or not the person shall have his or |
| 11 | | her license suspended immediately, pending a hearing by the |
| 12 | | Department.
|
| 13 | | In instances in which the Secretary immediately suspends a |
| 14 | | person's license under this Section, a hearing on that person's |
| 15 | | license must be convened by the Department within 15 days after |
| 16 | | the suspension and completed without appreciable delay. The |
| 17 | | Department may review the person's record of treatment and |
| 18 | | counseling regarding the impairment, to the extent permitted by |
| 19 | | applicable federal statutes and regulations safeguarding the |
| 20 | | confidentiality of medical records.
|
| 21 | | A person licensed under this Act and affected under this |
| 22 | | subsection (d) shall be afforded an opportunity to demonstrate |
| 23 | | to the Department that he or she can resume practice in |
| 24 | | compliance with acceptable and prevailing standards under the |
| 25 | | provisions of his or her license.
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| 1 | | Section 100. Failure to pay restitution. The Department, |
| 2 | | without further process or hearing, shall suspend the license |
| 3 | | or other authorization to practice of any person issued under |
| 4 | | this Act who has been certified by court order as not having |
| 5 | | paid restitution to a person under Section 8A-3.5 of the |
| 6 | | Illinois Public Aid Code, under Section 46-1 of the Criminal |
| 7 | | Code of 1961, or under Sections 17-8.5 or 17-10.5 of the |
| 8 | | Criminal Code of 2012. A person whose license or other |
| 9 | | authorization to practice is suspended under this Section is |
| 10 | | prohibited from practicing until restitution is made in full.
|
| 11 | | Section 105. Injunction; cease and desist order. |
| 12 | | (a) If a person violates any provision of this Act, the |
| 13 | | Secretary may, in the name of the People of the State of |
| 14 | | Illinois, through the Attorney General or the State's Attorney |
| 15 | | of any county in which the action is brought, petition for an |
| 16 | | order enjoining the violation or enforcing compliance with this |
| 17 | | Act. Upon the filing of a verified petition in court, the court |
| 18 | | may issue a temporary restraining order, without notice or |
| 19 | | bond, and may preliminarily and permanently enjoin the |
| 20 | | violation. If it is established that the person has violated or |
| 21 | | is violating the injunction, the court may punish the offender |
| 22 | | for contempt of court. Proceedings under this Section shall be |
| 23 | | in addition to, and not in lieu of, all other remedies and |
| 24 | | penalties provided by this Act.
|
| 25 | | (b) If any person practices as a licensed midwife or holds |
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| 1 | | himself or herself out as a licensed midwife without being |
| 2 | | licensed under the provisions of this Act, then any licensed |
| 3 | | midwife, any interested party, or any person injured thereby |
| 4 | | may, in addition to the Secretary, petition for relief as |
| 5 | | provided in subsection (a) of this Section.
|
| 6 | | (c) Whenever, in the opinion of the Department, any person |
| 7 | | violates any provision of this Act, the Department may issue a |
| 8 | | rule to show cause why an order to cease and desist should not |
| 9 | | be entered against that person. The rule shall clearly set |
| 10 | | forth the grounds relied upon by the Department and shall |
| 11 | | provide a period of 7 days after the date of the rule to file an |
| 12 | | answer to the satisfaction of the Department. Failure to answer |
| 13 | | to the satisfaction of the Department shall cause an order to |
| 14 | | cease and desist to be issued immediately.
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| 15 | | Section 110. Violation; criminal penalty. |
| 16 | | (a) Whoever knowingly practices or offers to practice |
| 17 | | midwifery in this State without being licensed for that purpose |
| 18 | | or exempt under this Act shall be guilty of a Class A |
| 19 | | misdemeanor and, for each subsequent conviction, shall be |
| 20 | | guilty of a Class 4 felony.
|
| 21 | | (b) Notwithstanding any other provision of this Act, all |
| 22 | | criminal fines, moneys, or other property collected or received |
| 23 | | by the Department under this Section or any other State or |
| 24 | | federal statute, including, but not limited to, property |
| 25 | | forfeited to the Department under Section 505 of the Illinois |
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| 1 | | Controlled Substances Act or Section 85 of the Methamphetamine |
| 2 | | Control and Community Protection Act, shall be deposited into |
| 3 | | the Professional Regulation Evidence Fund.
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| 4 | | Section 115. Investigation; notice; hearing. The |
| 5 | | Department may investigate the actions of any applicant or of |
| 6 | | any person or persons holding or claiming to hold a license |
| 7 | | under this Act. Before refusing to issue or to renew or taking |
| 8 | | any disciplinary action regarding a license, the Department |
| 9 | | shall, at least 30 days prior to the date set for the hearing, |
| 10 | | notify in writing the applicant or licensee of the nature of |
| 11 | | any charges and that a hearing shall be held on a date |
| 12 | | designated. The Department shall direct the applicant or |
| 13 | | licensee to file a written answer with the Board under oath |
| 14 | | within 20 days after the service of the notice and inform the |
| 15 | | applicant or licensee that failure to file an answer shall |
| 16 | | result in default being taken against the applicant or licensee |
| 17 | | and that the license may be suspended, revoked, or placed on |
| 18 | | probationary status or that other disciplinary action may be |
| 19 | | taken, including limiting the scope, nature, or extent of |
| 20 | | practice, as the Secretary may deem proper. Written notice may |
| 21 | | be served by personal delivery or certified or registered mail |
| 22 | | to the respondent at the address of his or her last |
| 23 | | notification to the Department. If the person fails to file an |
| 24 | | answer after receiving notice, his or her license may, in the |
| 25 | | discretion of the Department, be suspended, revoked, or placed |
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| 1 | | on probationary status, or the Department may take any |
| 2 | | disciplinary action deemed proper, including limiting the |
| 3 | | scope, nature, or extent of the person's practice or the |
| 4 | | imposition of a fine, without a hearing, if the act or acts |
| 5 | | charged constitute sufficient grounds for such action under |
| 6 | | this Act. At the time and place fixed in the notice, the Board |
| 7 | | shall proceed to hear the charges and the parties or their |
| 8 | | counsel shall be accorded ample opportunity to present such |
| 9 | | statements, testimony, evidence, and argument as may be |
| 10 | | pertinent to the charges or to their defense. The Board may |
| 11 | | continue a hearing from time to time.
|
| 12 | | Section 120. Formal hearing; preservation of record. The |
| 13 | | Department, at its expense, shall preserve a record of all |
| 14 | | proceedings at the formal hearing of any case. The notice of |
| 15 | | hearing, complaint, and all other documents in the nature of |
| 16 | | pleadings and written motions filed in the proceedings, the |
| 17 | | transcript of testimony, the report of the Board or hearing |
| 18 | | officer, and order of the Department shall be the record of the |
| 19 | | proceeding. The Department shall furnish a transcript of the |
| 20 | | record to any person interested in the hearing upon payment of |
| 21 | | the fee required under Section 2105-115 of the Department of |
| 22 | | Professional Regulation Law.
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| 23 | | Section 125. Witnesses; production of documents; contempt. |
| 24 | | Any circuit court may upon application of the Department or its |
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| 1 | | designee or of the applicant or licensee against whom |
| 2 | | proceedings under Section 95 of this Act are pending, enter an |
| 3 | | order requiring the attendance of witnesses and their testimony |
| 4 | | and the production of documents, papers, files, books, and |
| 5 | | records in connection with any hearing or investigation. The |
| 6 | | court may compel obedience to its order by proceedings for |
| 7 | | contempt.
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| 8 | | Section 130. Subpoena; oaths. The Department shall have the |
| 9 | | power to subpoena and bring before it any person in this State |
| 10 | | and to take testimony either orally or by deposition or both |
| 11 | | with the same fees and mileage and in the same manner as |
| 12 | | prescribed in civil cases in circuit courts of this State.
The |
| 13 | | Secretary, the designated hearing officer, and every member of |
| 14 | | the Board has the power to administer oaths to witnesses at any |
| 15 | | hearing that the Department is authorized to conduct and any |
| 16 | | other oaths authorized in any Act administered by the |
| 17 | | Department. Any circuit court may, upon application of the |
| 18 | | Department or its designee or upon application of the person |
| 19 | | against whom proceedings under this Act are pending, enter an |
| 20 | | order requiring the attendance of witnesses and their |
| 21 | | testimony, and the production of documents, papers, files, |
| 22 | | books, and records in connection with any hearing or |
| 23 | | investigation. The court may compel obedience to its order by |
| 24 | | proceedings for contempt.
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| 1 | | Section 135. Findings of fact, conclusions of law, and |
| 2 | | recommendations. At the conclusion of the hearing the Board |
| 3 | | shall present to the Secretary a written report of its findings |
| 4 | | of fact, conclusions of law, and recommendations. The report |
| 5 | | shall contain a finding as to whether or not the accused person |
| 6 | | violated this Act or failed to comply with the conditions |
| 7 | | required under this Act. The Board shall specify the nature of |
| 8 | | the violation or failure to comply and shall make its |
| 9 | | recommendations to the Secretary.
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| 10 | | The report of findings of fact, conclusions of law, and |
| 11 | | recommendations of the Board shall be the basis for the |
| 12 | | Department's order. If the Secretary disagrees in any regard |
| 13 | | with the report of the Board, the Secretary may issue an order |
| 14 | | in contravention of the report. The finding is not admissible |
| 15 | | in evidence against the person in a criminal prosecution |
| 16 | | brought for the violation of this Act, but the hearing and |
| 17 | | findings are not a bar to a criminal prosecution brought for |
| 18 | | the violation of this Act.
|
| 19 | | Section 140. Hearing officer. The Secretary may appoint any |
| 20 | | attorney duly licensed to practice law in the State of Illinois |
| 21 | | to serve as the hearing officer in any action for departmental |
| 22 | | refusal to issue, renew, or license an applicant or for |
| 23 | | disciplinary action against a licensee. The hearing officer |
| 24 | | shall have full authority to conduct the hearing. The hearing |
| 25 | | officer shall report his or her findings of fact, conclusions |
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| 1 | | of law, and recommendations to the Board and the Secretary. The |
| 2 | | Board shall have 60 calendar days after receipt of the report |
| 3 | | to review the report of the hearing officer and present its |
| 4 | | findings of fact, conclusions of law, and recommendations to |
| 5 | | the Secretary. If the Board fails to present its report within |
| 6 | | the 60-day period, the Secretary may issue an order based on |
| 7 | | the report of the hearing officer. If the Secretary disagrees |
| 8 | | with the recommendation of the Board or the hearing officer, he |
| 9 | | or she may issue an order in contravention of that |
| 10 | | recommendation.
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| 11 | | Section 145. Service of report; motion for rehearing. In |
| 12 | | any case involving the discipline of a license, a copy of the |
| 13 | | Board's report shall be served upon the respondent by the |
| 14 | | Department, either personally or as provided in this Act for |
| 15 | | the service of the notice of hearing. Within 20 days after the |
| 16 | | service, the respondent may present to the Department a motion |
| 17 | | in writing for a rehearing that shall specify the particular |
| 18 | | grounds for rehearing. If no motion for rehearing is filed, |
| 19 | | then upon the expiration of the time specified for filing a |
| 20 | | motion, or if a motion for rehearing is denied, then upon the |
| 21 | | denial, the Secretary may enter an order in accordance with |
| 22 | | this Act. If the respondent orders from the reporting service |
| 23 | | and pays for a transcript of the record within the time for |
| 24 | | filing a motion for rehearing, the 20-day period within which |
| 25 | | the motion may be filed shall commence upon the delivery of the |
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| 1 | | transcript to the respondent.
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| 2 | | Section 150. Rehearing. Whenever the Secretary is |
| 3 | | satisfied that substantial justice has not been done in the |
| 4 | | revocation, suspension, or refusal to issue or renew a license, |
| 5 | | the Secretary may order a rehearing by the same or another |
| 6 | | hearing officer or by the Board.
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| 7 | | Section 155. Prima facie proof. An order or a certified |
| 8 | | copy thereof, over the seal of the Department and purporting to |
| 9 | | be signed by the Secretary, shall be prima facie proof of the |
| 10 | | following:
|
| 11 | | (1) that the signature is the genuine signature of the |
| 12 | | Secretary;
|
| 13 | | (2) that such Secretary is duly appointed and |
| 14 | | qualified; and
|
| 15 | | (3) that the Board and its members are qualified to |
| 16 | | act.
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| 17 | | Section 160. Restoration of license. At any time after the |
| 18 | | suspension or revocation of any license, the Department may |
| 19 | | restore the license to the accused person, unless after an |
| 20 | | investigation and a hearing the Department determines that |
| 21 | | restoration is not in the public interest.
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| 22 | | Section 165. Surrender of license. Upon the revocation or |
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| 1 | | suspension of any license, the licensee shall immediately |
| 2 | | surrender the license to the Department. If the licensee fails |
| 3 | | to do so, the Department shall have the right to seize the |
| 4 | | license.
|
| 5 | | Section 170. Summary suspension. The Secretary may |
| 6 | | summarily suspend the license of a licensee under this Act |
| 7 | | without a hearing, simultaneously with the institution of |
| 8 | | proceedings for a hearing provided for in this Act, if the |
| 9 | | Secretary finds that evidence in his or her possession |
| 10 | | indicates that continuation in practice would constitute an |
| 11 | | imminent danger to the public. In the event that the Secretary |
| 12 | | summarily suspends a license without a hearing, a hearing by |
| 13 | | the Department must be held within 30 days after the suspension |
| 14 | | has occurred.
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| 15 | | Section 175. Certificate of record. The Department shall |
| 16 | | not be required to certify any record to the court or file any |
| 17 | | answer in court or otherwise appear in any court in a judicial |
| 18 | | review proceeding, unless there is filed in the court, with the |
| 19 | | complaint, a receipt from the Department acknowledging payment |
| 20 | | of the costs of furnishing and certifying the record. Failure |
| 21 | | on the part of the plaintiff to file a receipt in court shall |
| 22 | | be grounds for dismissal of the action.
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| 23 | | Section 180. Administrative Review Law. All final |
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| 1 | | administrative decisions of the Department are subject to |
| 2 | | judicial review under the Administrative Review Law and its |
| 3 | | rules. The term "administrative decision" is defined as in |
| 4 | | Section 3-101 of the Code of Civil Procedure.
|
| 5 | | Section 185. Illinois Administrative Procedure Act. The |
| 6 | | Illinois Administrative Procedure Act is hereby expressly |
| 7 | | adopted and incorporated in this Act as if all of the |
| 8 | | provisions of such Act were included in this Act, except that |
| 9 | | the provision of subsection (d) of Section 10-65 of the |
| 10 | | Illinois Administrative Procedure Act that provides that at |
| 11 | | hearings the licensee has the right to show compliance with all |
| 12 | | lawful requirements for retention, continuation, or renewal of |
| 13 | | the license is specifically excluded. For purposes of this Act, |
| 14 | | the notice required under Section 10-25 of the Illinois |
| 15 | | Administrative Procedure Act is deemed sufficient when mailed |
| 16 | | to the last known address of a party.
|
| 17 | | Section 190. Home rule. Pursuant to paragraph (h) of |
| 18 | | Section 6 of Article
VII
of the Illinois Constitution of 1970, |
| 19 | | the power to regulate and issue licenses for the practice of |
| 20 | | midwifery shall,
except as may otherwise be provided within and |
| 21 | | pursuant to the provisions of this Act, be exercised by the |
| 22 | | State and may
not be exercised by
any unit of local government, |
| 23 | | including home rule units.
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| 1 | | Section 195. Severability. The provisions of this Act are |
| 2 | | severable under Section 1.31 of the Statute on Statutes.
|
| 3 | | Section 900. The Regulatory Sunset Act is amended by adding |
| 4 | | Section 4.37 as follows:
|
| 5 | | (5 ILCS 80/4.37 new) |
| 6 | | Sec. 4.37. Act repealed on January 1, 2027. The following |
| 7 | | Act is repealed on January 1, 2027: |
| 8 | | The Home Birth Safety Act.
|
| 9 | | Section 905. The Medical Practice Act of 1987 is amended by |
| 10 | | changing Section 4 as follows:
|
| 11 | | (225 ILCS 60/4) (from Ch. 111, par. 4400-4)
|
| 12 | | (Section scheduled to be repealed on December 31, 2015)
|
| 13 | | Sec. 4. Exemptions. This Act does not apply to the |
| 14 | | following:
|
| 15 | | (1) persons lawfully carrying on their particular |
| 16 | | profession or business
under any valid existing regulatory |
| 17 | | Act of this State, including without limitation persons |
| 18 | | engaged in the practice of midwifery who are licensed under |
| 19 | | the Home Birth Safety Act;
|
| 20 | | (2) persons rendering gratuitous services in cases of |
| 21 | | emergency; or
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| 22 | | (3) persons treating human ailments by prayer or |
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| 1 | | spiritual means as an
exercise or enjoyment of religious |
| 2 | | freedom.
|
| 3 | | (Source: P.A. 96-7, eff. 4-3-09; 97-622, eff. 11-23-11.)
|
| 4 | | Section 910. The Nurse Practice Act is amended by changing |
| 5 | | Section 50-15 as follows:
|
| 6 | | (225 ILCS 65/50-15)
(was 225 ILCS 65/5-15)
|
| 7 | | (Section scheduled to be repealed on January 1, 2018)
|
| 8 | | Sec. 50-15. Policy; application of Act. |
| 9 | | (a) For the protection of life and the
promotion of health, |
| 10 | | and the prevention of illness and communicable diseases,
any |
| 11 | | person practicing or offering to practice advanced,
|
| 12 | | professional, or practical
nursing in Illinois shall submit |
| 13 | | evidence that he or she is qualified to
practice, and shall be |
| 14 | | licensed as provided under this Act. No person shall
practice |
| 15 | | or offer to practice advanced, professional, or practical |
| 16 | | nursing in Illinois or
use any title, sign, card or device to |
| 17 | | indicate that such a person is
practicing professional or |
| 18 | | practical nursing unless such person has been
licensed under |
| 19 | | the provisions of this Act.
|
| 20 | | (b) This Act does not prohibit the following:
|
| 21 | | (1) The practice of nursing in Federal employment in |
| 22 | | the discharge of the
employee's duties by a person who is |
| 23 | | employed by the United States
government or any bureau, |
| 24 | | division or agency thereof and is a legally
qualified and |
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| 1 | | licensed nurse of another state or territory and not in
|
| 2 | | conflict with Sections 50-50, 55-10, 60-10, and 70-5 of |
| 3 | | this
Act.
|
| 4 | | (2) Nursing that is included in the program of study by
|
| 5 | | students
enrolled in programs of nursing or in current |
| 6 | | nurse practice update courses
approved by the Department.
|
| 7 | | (3) The furnishing of nursing assistance in an |
| 8 | | emergency.
|
| 9 | | (4) The practice of nursing by a nurse who holds an |
| 10 | | active license in
another state when providing services to |
| 11 | | patients in Illinois during a bonafide
emergency or in |
| 12 | | immediate preparation for or during interstate
transit.
|
| 13 | | (5) The incidental care of the sick by members of the |
| 14 | | family, domestic
servants or housekeepers, or care of the |
| 15 | | sick where treatment is by prayer
or spiritual means.
|
| 16 | | (6) Persons from being employed as unlicensed |
| 17 | | assistive personnel in private homes, long term care |
| 18 | | facilities,
nurseries, hospitals or other institutions.
|
| 19 | | (7) The practice of practical nursing by one who is a |
| 20 | | licensed practical
nurse under the laws of another U.S. |
| 21 | | jurisdiction and has applied in writing
to the Department, |
| 22 | | in form and substance satisfactory to the Department,
for a |
| 23 | | license as a licensed practical nurse and who is qualified |
| 24 | | to receive
such license under this Act, until (i) the |
| 25 | | expiration of 6 months after
the filing of such written |
| 26 | | application, (ii) the withdrawal of such application,
or |
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| 1 | | (iii) the denial of such application by the Department.
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| 2 | | (8) The practice of advanced practice nursing by one |
| 3 | | who is an advanced practice nurse under the laws of another |
| 4 | | state, territory of the United States, or country and has |
| 5 | | applied in writing to the Department, in form and substance |
| 6 | | satisfactory to the Department, for a license as an |
| 7 | | advanced practice nurse and who is qualified to receive |
| 8 | | such license under this Act, until (i) the expiration of 6 |
| 9 | | months after the filing of such written application, (ii) |
| 10 | | the withdrawal of such application, or (iii) the denial of |
| 11 | | such application by the Department.
|
| 12 | | (9) The practice of professional nursing by one who is |
| 13 | | a registered
professional nurse under the laws of another |
| 14 | | state, territory of the United
States or country and has |
| 15 | | applied in writing to the Department, in form and
substance |
| 16 | | satisfactory to the Department, for a license as a |
| 17 | | registered
professional nurse and who is qualified to |
| 18 | | receive such license under
Section 55-10, until (1) the |
| 19 | | expiration of 6 months after the filing of
such written |
| 20 | | application, (2) the withdrawal of such application, or (3)
|
| 21 | | the denial of such application by the Department.
|
| 22 | | (10) The practice of professional nursing that is |
| 23 | | included in a program of
study by one who is a registered |
| 24 | | professional nurse under the laws of
another state or |
| 25 | | territory of the United States or foreign country,
|
| 26 | | territory or province and who is enrolled in a graduate |
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| 1 | | nursing education
program or a program for the completion |
| 2 | | of a baccalaureate nursing degree in
this State, which |
| 3 | | includes clinical supervision by faculty as
determined by |
| 4 | | the educational institution offering the program and the
|
| 5 | | health care organization where the practice of nursing |
| 6 | | occurs.
|
| 7 | | (11) Any person licensed in this State under any other |
| 8 | | Act from engaging
in the practice for which she or he is |
| 9 | | licensed, including without limitation any person engaged |
| 10 | | in the practice of midwifery who is licensed under the Home |
| 11 | | Birth Safety Act.
|
| 12 | | (12) Delegation to authorized direct care staff |
| 13 | | trained under Section 15.4
of the Mental Health and
|
| 14 | | Developmental Disabilities Administrative Act consistent |
| 15 | | with the policies of the Department.
|
| 16 | | (13) The practice, services, or activities of persons |
| 17 | | practicing the specified occupations set forth in |
| 18 | | subsection (a) of, and pursuant to a licensing exemption |
| 19 | | granted in subsection (b) or (d) of, Section 2105-350 of |
| 20 | | the Department of Professional Regulation Law of the Civil |
| 21 | | Administrative Code of Illinois, but only for so long as |
| 22 | | the 2016 Olympic and Paralympic Games Professional |
| 23 | | Licensure Exemption Law is operable. |
| 24 | | (14) County correctional personnel from delivering |
| 25 | | prepackaged medication for self-administration to an |
| 26 | | individual detainee in a correctional facility. |
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| 1 | | Nothing in this Act shall be construed to limit the |
| 2 | | delegation of tasks or duties by a physician, dentist, or |
| 3 | | podiatric physician to a licensed practical nurse, a registered |
| 4 | | professional nurse, or other persons.
|
| 5 | | (Source: P.A. 98-214, eff. 8-9-13.)
|
| 6 | | Section 990. The Illinois Public Aid Code is amended by |
| 7 | | changing Section 5-5 as follows:
|
| 8 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
|
| 9 | | (Text of Section before amendment by P.A. 99-407) |
| 10 | | Sec. 5-5. Medical services. The Illinois Department, by |
| 11 | | rule, shall
determine the quantity and quality of and the rate |
| 12 | | of reimbursement for the
medical assistance for which
payment |
| 13 | | will be authorized, and the medical services to be provided,
|
| 14 | | which may include all or part of the following: (1) inpatient |
| 15 | | hospital
services; (2) outpatient hospital services; (3) other |
| 16 | | laboratory and
X-ray services; (4) skilled nursing home |
| 17 | | services; (5) physicians'
services whether furnished in the |
| 18 | | office, the patient's home, a
hospital, a skilled nursing home, |
| 19 | | or elsewhere; (6) medical care, or any
other type of remedial |
| 20 | | care furnished by licensed practitioners, including the |
| 21 | | services of certified professional midwives licensed pursuant |
| 22 | | to the Home Birth Safety Act; (7)
home health care services; |
| 23 | | (8) private duty nursing service; (9) clinic
services; (10) |
| 24 | | dental services, including prevention and treatment of |
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| 1 | | periodontal disease and dental caries disease for pregnant |
| 2 | | women, provided by an individual licensed to practice dentistry |
| 3 | | or dental surgery; for purposes of this item (10), "dental |
| 4 | | services" means diagnostic, preventive, or corrective |
| 5 | | procedures provided by or under the supervision of a dentist in |
| 6 | | the practice of his or her profession; (11) physical therapy |
| 7 | | and related
services; (12) prescribed drugs, dentures, and |
| 8 | | prosthetic devices; and
eyeglasses prescribed by a physician |
| 9 | | skilled in the diseases of the eye,
or by an optometrist, |
| 10 | | whichever the person may select; (13) other
diagnostic, |
| 11 | | screening, preventive, and rehabilitative services, including |
| 12 | | to ensure that the individual's need for intervention or |
| 13 | | treatment of mental disorders or substance use disorders or |
| 14 | | co-occurring mental health and substance use disorders is |
| 15 | | determined using a uniform screening, assessment, and |
| 16 | | evaluation process inclusive of criteria, for children and |
| 17 | | adults; for purposes of this item (13), a uniform screening, |
| 18 | | assessment, and evaluation process refers to a process that |
| 19 | | includes an appropriate evaluation and, as warranted, a |
| 20 | | referral; "uniform" does not mean the use of a singular |
| 21 | | instrument, tool, or process that all must utilize; (14)
|
| 22 | | transportation and such other expenses as may be necessary; |
| 23 | | (15) medical
treatment of sexual assault survivors, as defined |
| 24 | | in
Section 1a of the Sexual Assault Survivors Emergency |
| 25 | | Treatment Act, for
injuries sustained as a result of the sexual |
| 26 | | assault, including
examinations and laboratory tests to |
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| 1 | | discover evidence which may be used in
criminal proceedings |
| 2 | | arising from the sexual assault; (16) the
diagnosis and |
| 3 | | treatment of sickle cell anemia; and (17)
any other medical |
| 4 | | care, and any other type of remedial care recognized
under the |
| 5 | | laws of this State, but not including abortions, or induced
|
| 6 | | miscarriages or premature births, unless, in the opinion of a |
| 7 | | physician,
such procedures are necessary for the preservation |
| 8 | | of the life of the
woman seeking such treatment, or except an |
| 9 | | induced premature birth
intended to produce a live viable child |
| 10 | | and such procedure is necessary
for the health of the mother or |
| 11 | | her unborn child. The Illinois Department,
by rule, shall |
| 12 | | prohibit any physician from providing medical assistance
to |
| 13 | | anyone eligible therefor under this Code where such physician |
| 14 | | has been
found guilty of performing an abortion procedure in a |
| 15 | | wilful and wanton
manner upon a woman who was not pregnant at |
| 16 | | the time such abortion
procedure was performed. The term "any |
| 17 | | other type of remedial care" shall
include nursing care and |
| 18 | | nursing home service for persons who rely on
treatment by |
| 19 | | spiritual means alone through prayer for healing.
|
| 20 | | Notwithstanding any other provision of this Section, a |
| 21 | | comprehensive
tobacco use cessation program that includes |
| 22 | | purchasing prescription drugs or
prescription medical devices |
| 23 | | approved by the Food and Drug Administration shall
be covered |
| 24 | | under the medical assistance
program under this Article for |
| 25 | | persons who are otherwise eligible for
assistance under this |
| 26 | | Article.
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| 1 | | Notwithstanding any other provision of this Code, the |
| 2 | | Illinois
Department may not require, as a condition of payment |
| 3 | | for any laboratory
test authorized under this Article, that a |
| 4 | | physician's handwritten signature
appear on the laboratory |
| 5 | | test order form. The Illinois Department may,
however, impose |
| 6 | | other appropriate requirements regarding laboratory test
order |
| 7 | | documentation.
|
| 8 | | Upon receipt of federal approval of an amendment to the |
| 9 | | Illinois Title XIX State Plan for this purpose, the Department |
| 10 | | shall authorize the Chicago Public Schools (CPS) to procure a |
| 11 | | vendor or vendors to manufacture eyeglasses for individuals |
| 12 | | enrolled in a school within the CPS system. CPS shall ensure |
| 13 | | that its vendor or vendors are enrolled as providers in the |
| 14 | | medical assistance program and in any capitated Medicaid |
| 15 | | managed care entity (MCE) serving individuals enrolled in a |
| 16 | | school within the CPS system. Under any contract procured under |
| 17 | | this provision, the vendor or vendors must serve only |
| 18 | | individuals enrolled in a school within the CPS system. Claims |
| 19 | | for services provided by CPS's vendor or vendors to recipients |
| 20 | | of benefits in the medical assistance program under this Code, |
| 21 | | the Children's Health Insurance Program, or the Covering ALL |
| 22 | | KIDS Health Insurance Program shall be submitted to the |
| 23 | | Department or the MCE in which the individual is enrolled for |
| 24 | | payment and shall be reimbursed at the Department's or the |
| 25 | | MCE's established rates or rate methodologies for eyeglasses. |
| 26 | | On and after July 1, 2012, the Department of Healthcare and |
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| 1 | | Family Services may provide the following services to
persons
|
| 2 | | eligible for assistance under this Article who are |
| 3 | | participating in
education, training or employment programs |
| 4 | | operated by the Department of Human
Services as successor to |
| 5 | | the Department of Public Aid:
|
| 6 | | (1) dental services provided by or under the |
| 7 | | supervision of a dentist; and
|
| 8 | | (2) eyeglasses prescribed by a physician skilled in the |
| 9 | | diseases of the
eye, or by an optometrist, whichever the |
| 10 | | person may select.
|
| 11 | | Notwithstanding any other provision of this Code and |
| 12 | | subject to federal approval, the Department may adopt rules to |
| 13 | | allow a dentist who is volunteering his or her service at no |
| 14 | | cost to render dental services through an enrolled |
| 15 | | not-for-profit health clinic without the dentist personally |
| 16 | | enrolling as a participating provider in the medical assistance |
| 17 | | program. A not-for-profit health clinic shall include a public |
| 18 | | health clinic or Federally Qualified Health Center or other |
| 19 | | enrolled provider, as determined by the Department, through |
| 20 | | which dental services covered under this Section are performed. |
| 21 | | The Department shall establish a process for payment of claims |
| 22 | | for reimbursement for covered dental services rendered under |
| 23 | | this provision. |
| 24 | | The Illinois Department, by rule, may distinguish and |
| 25 | | classify the
medical services to be provided only in accordance |
| 26 | | with the classes of
persons designated in Section 5-2.
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| 1 | | The Department of Healthcare and Family Services must |
| 2 | | provide coverage and reimbursement for amino acid-based |
| 3 | | elemental formulas, regardless of delivery method, for the |
| 4 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
| 5 | | short bowel syndrome when the prescribing physician has issued |
| 6 | | a written order stating that the amino acid-based elemental |
| 7 | | formula is medically necessary.
|
| 8 | | The Illinois Department shall authorize the provision of, |
| 9 | | and shall
authorize payment for, screening by low-dose |
| 10 | | mammography for the presence of
occult breast cancer for women |
| 11 | | 35 years of age or older who are eligible
for medical |
| 12 | | assistance under this Article, as follows: |
| 13 | | (A) A baseline
mammogram for women 35 to 39 years of |
| 14 | | age.
|
| 15 | | (B) An annual mammogram for women 40 years of age or |
| 16 | | older. |
| 17 | | (C) A mammogram at the age and intervals considered |
| 18 | | medically necessary by the woman's health care provider for |
| 19 | | women under 40 years of age and having a family history of |
| 20 | | breast cancer, prior personal history of breast cancer, |
| 21 | | positive genetic testing, or other risk factors. |
| 22 | | (D) A comprehensive ultrasound screening of an entire |
| 23 | | breast or breasts if a mammogram demonstrates |
| 24 | | heterogeneous or dense breast tissue, when medically |
| 25 | | necessary as determined by a physician licensed to practice |
| 26 | | medicine in all of its branches. |
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| 1 | | (E) A screening MRI when medically necessary, as |
| 2 | | determined by a physician licensed to practice medicine in |
| 3 | | all of its branches. |
| 4 | | All screenings
shall
include a physical breast exam, |
| 5 | | instruction on self-examination and
information regarding the |
| 6 | | frequency of self-examination and its value as a
preventative |
| 7 | | tool. For purposes of this Section, "low-dose mammography" |
| 8 | | means
the x-ray examination of the breast using equipment |
| 9 | | dedicated specifically
for mammography, including the x-ray |
| 10 | | tube, filter, compression device,
and image receptor, with an |
| 11 | | average radiation exposure delivery
of less than one rad per |
| 12 | | breast for 2 views of an average size breast.
The term also |
| 13 | | includes digital mammography.
|
| 14 | | On and after January 1, 2016, the Department shall ensure |
| 15 | | that all networks of care for adult clients of the Department |
| 16 | | include access to at least one breast imaging Center of Imaging |
| 17 | | Excellence as certified by the American College of Radiology. |
| 18 | | On and after January 1, 2012, providers participating in a |
| 19 | | quality improvement program approved by the Department shall be |
| 20 | | reimbursed for screening and diagnostic mammography at the same |
| 21 | | rate as the Medicare program's rates, including the increased |
| 22 | | reimbursement for digital mammography. |
| 23 | | The Department shall convene an expert panel including |
| 24 | | representatives of hospitals, free-standing mammography |
| 25 | | facilities, and doctors, including radiologists, to establish |
| 26 | | quality standards for mammography. |
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| 1 | | On and after January 1, 2017, providers participating in a |
| 2 | | breast cancer treatment quality improvement program approved |
| 3 | | by the Department shall be reimbursed for breast cancer |
| 4 | | treatment at a rate that is no lower than 95% of the Medicare |
| 5 | | program's rates for the data elements included in the breast |
| 6 | | cancer treatment quality program. |
| 7 | | The Department shall convene an expert panel, including |
| 8 | | representatives of hospitals, free standing breast cancer |
| 9 | | treatment centers, breast cancer quality organizations, and |
| 10 | | doctors, including breast surgeons, reconstructive breast |
| 11 | | surgeons, oncologists, and primary care providers to establish |
| 12 | | quality standards for breast cancer treatment. |
| 13 | | Subject to federal approval, the Department shall |
| 14 | | establish a rate methodology for mammography at federally |
| 15 | | qualified health centers and other encounter-rate clinics. |
| 16 | | These clinics or centers may also collaborate with other |
| 17 | | hospital-based mammography facilities. By January 1, 2016, the |
| 18 | | Department shall report to the General Assembly on the status |
| 19 | | of the provision set forth in this paragraph. |
| 20 | | The Department shall establish a methodology to remind |
| 21 | | women who are age-appropriate for screening mammography, but |
| 22 | | who have not received a mammogram within the previous 18 |
| 23 | | months, of the importance and benefit of screening mammography. |
| 24 | | The Department shall work with experts in breast cancer |
| 25 | | outreach and patient navigation to optimize these reminders and |
| 26 | | shall establish a methodology for evaluating their |
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| 1 | | effectiveness and modifying the methodology based on the |
| 2 | | evaluation. |
| 3 | | The Department shall establish a performance goal for |
| 4 | | primary care providers with respect to their female patients |
| 5 | | over age 40 receiving an annual mammogram. This performance |
| 6 | | goal shall be used to provide additional reimbursement in the |
| 7 | | form of a quality performance bonus to primary care providers |
| 8 | | who meet that goal. |
| 9 | | The Department shall devise a means of case-managing or |
| 10 | | patient navigation for beneficiaries diagnosed with breast |
| 11 | | cancer. This program shall initially operate as a pilot program |
| 12 | | in areas of the State with the highest incidence of mortality |
| 13 | | related to breast cancer. At least one pilot program site shall |
| 14 | | be in the metropolitan Chicago area and at least one site shall |
| 15 | | be outside the metropolitan Chicago area. On or after July 1, |
| 16 | | 2016, the pilot program shall be expanded to include one site |
| 17 | | in western Illinois, one site in southern Illinois, one site in |
| 18 | | central Illinois, and 4 sites within metropolitan Chicago. An |
| 19 | | evaluation of the pilot program shall be carried out measuring |
| 20 | | health outcomes and cost of care for those served by the pilot |
| 21 | | program compared to similarly situated patients who are not |
| 22 | | served by the pilot program. |
| 23 | | The Department shall require all networks of care to |
| 24 | | develop a means either internally or by contract with experts |
| 25 | | in navigation and community outreach to navigate cancer |
| 26 | | patients to comprehensive care in a timely fashion. The |
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| 1 | | Department shall require all networks of care to include access |
| 2 | | for patients diagnosed with cancer to at least one academic |
| 3 | | commission on cancer-accredited cancer program as an |
| 4 | | in-network covered benefit. |
| 5 | | Any medical or health care provider shall immediately |
| 6 | | recommend, to
any pregnant woman who is being provided prenatal |
| 7 | | services and is suspected
of drug abuse or is addicted as |
| 8 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
| 9 | | Act, referral to a local substance abuse treatment provider
|
| 10 | | licensed by the Department of Human Services or to a licensed
|
| 11 | | hospital which provides substance abuse treatment services. |
| 12 | | The Department of Healthcare and Family Services
shall assure |
| 13 | | coverage for the cost of treatment of the drug abuse or
|
| 14 | | addiction for pregnant recipients in accordance with the |
| 15 | | Illinois Medicaid
Program in conjunction with the Department of |
| 16 | | Human Services.
|
| 17 | | All medical providers providing medical assistance to |
| 18 | | pregnant women
under this Code shall receive information from |
| 19 | | the Department on the
availability of services under the Drug |
| 20 | | Free Families with a Future or any
comparable program providing |
| 21 | | case management services for addicted women,
including |
| 22 | | information on appropriate referrals for other social services
|
| 23 | | that may be needed by addicted women in addition to treatment |
| 24 | | for addiction.
|
| 25 | | The Illinois Department, in cooperation with the |
| 26 | | Departments of Human
Services (as successor to the Department |
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| 1 | | of Alcoholism and Substance
Abuse) and Public Health, through a |
| 2 | | public awareness campaign, may
provide information concerning |
| 3 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
| 4 | | health care, and other pertinent programs directed at
reducing |
| 5 | | the number of drug-affected infants born to recipients of |
| 6 | | medical
assistance.
|
| 7 | | Neither the Department of Healthcare and Family Services |
| 8 | | nor the Department of Human
Services shall sanction the |
| 9 | | recipient solely on the basis of
her substance abuse.
|
| 10 | | The Illinois Department shall establish such regulations |
| 11 | | governing
the dispensing of health services under this Article |
| 12 | | as it shall deem
appropriate. The Department
should
seek the |
| 13 | | advice of formal professional advisory committees appointed by
|
| 14 | | the Director of the Illinois Department for the purpose of |
| 15 | | providing regular
advice on policy and administrative matters, |
| 16 | | information dissemination and
educational activities for |
| 17 | | medical and health care providers, and
consistency in |
| 18 | | procedures to the Illinois Department.
|
| 19 | | The Illinois Department may develop and contract with |
| 20 | | Partnerships of
medical providers to arrange medical services |
| 21 | | for persons eligible under
Section 5-2 of this Code. |
| 22 | | Implementation of this Section may be by
demonstration projects |
| 23 | | in certain geographic areas. The Partnership shall
be |
| 24 | | represented by a sponsor organization. The Department, by rule, |
| 25 | | shall
develop qualifications for sponsors of Partnerships. |
| 26 | | Nothing in this
Section shall be construed to require that the |
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| 1 | | sponsor organization be a
medical organization.
|
| 2 | | The sponsor must negotiate formal written contracts with |
| 3 | | medical
providers for physician services, inpatient and |
| 4 | | outpatient hospital care,
home health services, treatment for |
| 5 | | alcoholism and substance abuse, and
other services determined |
| 6 | | necessary by the Illinois Department by rule for
delivery by |
| 7 | | Partnerships. Physician services must include prenatal and
|
| 8 | | obstetrical care. The Illinois Department shall reimburse |
| 9 | | medical services
delivered by Partnership providers to clients |
| 10 | | in target areas according to
provisions of this Article and the |
| 11 | | Illinois Health Finance Reform Act,
except that:
|
| 12 | | (1) Physicians participating in a Partnership and |
| 13 | | providing certain
services, which shall be determined by |
| 14 | | the Illinois Department, to persons
in areas covered by the |
| 15 | | Partnership may receive an additional surcharge
for such |
| 16 | | services.
|
| 17 | | (2) The Department may elect to consider and negotiate |
| 18 | | financial
incentives to encourage the development of |
| 19 | | Partnerships and the efficient
delivery of medical care.
|
| 20 | | (3) Persons receiving medical services through |
| 21 | | Partnerships may receive
medical and case management |
| 22 | | services above the level usually offered
through the |
| 23 | | medical assistance program.
|
| 24 | | Medical providers shall be required to meet certain |
| 25 | | qualifications to
participate in Partnerships to ensure the |
| 26 | | delivery of high quality medical
services. These |
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| 1 | | qualifications shall be determined by rule of the Illinois
|
| 2 | | Department and may be higher than qualifications for |
| 3 | | participation in the
medical assistance program. Partnership |
| 4 | | sponsors may prescribe reasonable
additional qualifications |
| 5 | | for participation by medical providers, only with
the prior |
| 6 | | written approval of the Illinois Department.
|
| 7 | | Nothing in this Section shall limit the free choice of |
| 8 | | practitioners,
hospitals, and other providers of medical |
| 9 | | services by clients.
In order to ensure patient freedom of |
| 10 | | choice, the Illinois Department shall
immediately promulgate |
| 11 | | all rules and take all other necessary actions so that
provided |
| 12 | | services may be accessed from therapeutically certified |
| 13 | | optometrists
to the full extent of the Illinois Optometric |
| 14 | | Practice Act of 1987 without
discriminating between service |
| 15 | | providers.
|
| 16 | | The Department shall apply for a waiver from the United |
| 17 | | States Health
Care Financing Administration to allow for the |
| 18 | | implementation of
Partnerships under this Section.
|
| 19 | | The Illinois Department shall require health care |
| 20 | | providers to maintain
records that document the medical care |
| 21 | | and services provided to recipients
of Medical Assistance under |
| 22 | | this Article. Such records must be retained for a period of not |
| 23 | | less than 6 years from the date of service or as provided by |
| 24 | | applicable State law, whichever period is longer, except that |
| 25 | | if an audit is initiated within the required retention period |
| 26 | | then the records must be retained until the audit is completed |
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| 1 | | and every exception is resolved. The Illinois Department shall
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| 2 | | require health care providers to make available, when |
| 3 | | authorized by the
patient, in writing, the medical records in a |
| 4 | | timely fashion to other
health care providers who are treating |
| 5 | | or serving persons eligible for
Medical Assistance under this |
| 6 | | Article. All dispensers of medical services
shall be required |
| 7 | | to maintain and retain business and professional records
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| 8 | | sufficient to fully and accurately document the nature, scope, |
| 9 | | details and
receipt of the health care provided to persons |
| 10 | | eligible for medical
assistance under this Code, in accordance |
| 11 | | with regulations promulgated by
the Illinois Department. The |
| 12 | | rules and regulations shall require that proof
of the receipt |
| 13 | | of prescription drugs, dentures, prosthetic devices and
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| 14 | | eyeglasses by eligible persons under this Section accompany |
| 15 | | each claim
for reimbursement submitted by the dispenser of such |
| 16 | | medical services.
No such claims for reimbursement shall be |
| 17 | | approved for payment by the Illinois
Department without such |
| 18 | | proof of receipt, unless the Illinois Department
shall have put |
| 19 | | into effect and shall be operating a system of post-payment
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| 20 | | audit and review which shall, on a sampling basis, be deemed |
| 21 | | adequate by
the Illinois Department to assure that such drugs, |
| 22 | | dentures, prosthetic
devices and eyeglasses for which payment |
| 23 | | is being made are actually being
received by eligible |
| 24 | | recipients. Within 90 days after the effective date of
this |
| 25 | | amendatory Act of 1984, the Illinois Department shall establish |
| 26 | | a
current list of acquisition costs for all prosthetic devices |
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| 1 | | and any
other items recognized as medical equipment and |
| 2 | | supplies reimbursable under
this Article and shall update such |
| 3 | | list on a quarterly basis, except that
the acquisition costs of |
| 4 | | all prescription drugs shall be updated no
less frequently than |
| 5 | | every 30 days as required by Section 5-5.12.
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| 6 | | The rules and regulations of the Illinois Department shall |
| 7 | | require
that a written statement including the required opinion |
| 8 | | of a physician
shall accompany any claim for reimbursement for |
| 9 | | abortions, or induced
miscarriages or premature births. This |
| 10 | | statement shall indicate what
procedures were used in providing |
| 11 | | such medical services.
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| 12 | | Notwithstanding any other law to the contrary, the Illinois |
| 13 | | Department shall, within 365 days after July 22, 2013 (the |
| 14 | | effective date of Public Act 98-104), establish procedures to |
| 15 | | permit skilled care facilities licensed under the Nursing Home |
| 16 | | Care Act to submit monthly billing claims for reimbursement |
| 17 | | purposes. Following development of these procedures, the |
| 18 | | Department shall, by July 1, 2016, test the viability of the |
| 19 | | new system and implement any necessary operational or |
| 20 | | structural changes to its information technology platforms in |
| 21 | | order to allow for the direct acceptance and payment of nursing |
| 22 | | home claims. |
| 23 | | Notwithstanding any other law to the contrary, the Illinois |
| 24 | | Department shall, within 365 days after August 15, 2014 (the |
| 25 | | effective date of Public Act 98-963), establish procedures to |
| 26 | | permit ID/DD facilities licensed under the ID/DD Community Care |
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| 1 | | Act and MC/DD facilities licensed under the MC/DD Act to submit |
| 2 | | monthly billing claims for reimbursement purposes. Following |
| 3 | | development of these procedures, the Department shall have an |
| 4 | | additional 365 days to test the viability of the new system and |
| 5 | | to ensure that any necessary operational or structural changes |
| 6 | | to its information technology platforms are implemented. |
| 7 | | The Illinois Department shall require all dispensers of |
| 8 | | medical
services, other than an individual practitioner or |
| 9 | | group of practitioners,
desiring to participate in the Medical |
| 10 | | Assistance program
established under this Article to disclose |
| 11 | | all financial, beneficial,
ownership, equity, surety or other |
| 12 | | interests in any and all firms,
corporations, partnerships, |
| 13 | | associations, business enterprises, joint
ventures, agencies, |
| 14 | | institutions or other legal entities providing any
form of |
| 15 | | health care services in this State under this Article.
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| 16 | | The Illinois Department may require that all dispensers of |
| 17 | | medical
services desiring to participate in the medical |
| 18 | | assistance program
established under this Article disclose, |
| 19 | | under such terms and conditions as
the Illinois Department may |
| 20 | | by rule establish, all inquiries from clients
and attorneys |
| 21 | | regarding medical bills paid by the Illinois Department, which
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| 22 | | inquiries could indicate potential existence of claims or liens |
| 23 | | for the
Illinois Department.
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| 24 | | Enrollment of a vendor
shall be
subject to a provisional |
| 25 | | period and shall be conditional for one year. During the period |
| 26 | | of conditional enrollment, the Department may
terminate the |
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| 1 | | vendor's eligibility to participate in, or may disenroll the |
| 2 | | vendor from, the medical assistance
program without cause. |
| 3 | | Unless otherwise specified, such termination of eligibility or |
| 4 | | disenrollment is not subject to the
Department's hearing |
| 5 | | process.
However, a disenrolled vendor may reapply without |
| 6 | | penalty.
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| 7 | | The Department has the discretion to limit the conditional |
| 8 | | enrollment period for vendors based upon category of risk of |
| 9 | | the vendor. |
| 10 | | Prior to enrollment and during the conditional enrollment |
| 11 | | period in the medical assistance program, all vendors shall be |
| 12 | | subject to enhanced oversight, screening, and review based on |
| 13 | | the risk of fraud, waste, and abuse that is posed by the |
| 14 | | category of risk of the vendor. The Illinois Department shall |
| 15 | | establish the procedures for oversight, screening, and review, |
| 16 | | which may include, but need not be limited to: criminal and |
| 17 | | financial background checks; fingerprinting; license, |
| 18 | | certification, and authorization verifications; unscheduled or |
| 19 | | unannounced site visits; database checks; prepayment audit |
| 20 | | reviews; audits; payment caps; payment suspensions; and other |
| 21 | | screening as required by federal or State law. |
| 22 | | The Department shall define or specify the following: (i) |
| 23 | | by provider notice, the "category of risk of the vendor" for |
| 24 | | each type of vendor, which shall take into account the level of |
| 25 | | screening applicable to a particular category of vendor under |
| 26 | | federal law and regulations; (ii) by rule or provider notice, |
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| 1 | | the maximum length of the conditional enrollment period for |
| 2 | | each category of risk of the vendor; and (iii) by rule, the |
| 3 | | hearing rights, if any, afforded to a vendor in each category |
| 4 | | of risk of the vendor that is terminated or disenrolled during |
| 5 | | the conditional enrollment period. |
| 6 | | To be eligible for payment consideration, a vendor's |
| 7 | | payment claim or bill, either as an initial claim or as a |
| 8 | | resubmitted claim following prior rejection, must be received |
| 9 | | by the Illinois Department, or its fiscal intermediary, no |
| 10 | | later than 180 days after the latest date on the claim on which |
| 11 | | medical goods or services were provided, with the following |
| 12 | | exceptions: |
| 13 | | (1) In the case of a provider whose enrollment is in |
| 14 | | process by the Illinois Department, the 180-day period |
| 15 | | shall not begin until the date on the written notice from |
| 16 | | the Illinois Department that the provider enrollment is |
| 17 | | complete. |
| 18 | | (2) In the case of errors attributable to the Illinois |
| 19 | | Department or any of its claims processing intermediaries |
| 20 | | which result in an inability to receive, process, or |
| 21 | | adjudicate a claim, the 180-day period shall not begin |
| 22 | | until the provider has been notified of the error. |
| 23 | | (3) In the case of a provider for whom the Illinois |
| 24 | | Department initiates the monthly billing process. |
| 25 | | (4) In the case of a provider operated by a unit of |
| 26 | | local government with a population exceeding 3,000,000 |
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| 1 | | when local government funds finance federal participation |
| 2 | | for claims payments. |
| 3 | | For claims for services rendered during a period for which |
| 4 | | a recipient received retroactive eligibility, claims must be |
| 5 | | filed within 180 days after the Department determines the |
| 6 | | applicant is eligible. For claims for which the Illinois |
| 7 | | Department is not the primary payer, claims must be submitted |
| 8 | | to the Illinois Department within 180 days after the final |
| 9 | | adjudication by the primary payer. |
| 10 | | In the case of long term care facilities, within 5 days of |
| 11 | | receipt by the facility of required prescreening information, |
| 12 | | data for new admissions shall be entered into the Medical |
| 13 | | Electronic Data Interchange (MEDI) or the Recipient |
| 14 | | Eligibility Verification (REV) System or successor system, and |
| 15 | | within 15 days of receipt by the facility of required |
| 16 | | prescreening information, admission documents shall be |
| 17 | | submitted through MEDI or REV or shall be submitted directly to |
| 18 | | the Department of Human Services using required admission |
| 19 | | forms. Effective September
1, 2014, admission documents, |
| 20 | | including all prescreening
information, must be submitted |
| 21 | | through MEDI or REV. Confirmation numbers assigned to an |
| 22 | | accepted transaction shall be retained by a facility to verify |
| 23 | | timely submittal. Once an admission transaction has been |
| 24 | | completed, all resubmitted claims following prior rejection |
| 25 | | are subject to receipt no later than 180 days after the |
| 26 | | admission transaction has been completed. |
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| 1 | | Claims that are not submitted and received in compliance |
| 2 | | with the foregoing requirements shall not be eligible for |
| 3 | | payment under the medical assistance program, and the State |
| 4 | | shall have no liability for payment of those claims. |
| 5 | | To the extent consistent with applicable information and |
| 6 | | privacy, security, and disclosure laws, State and federal |
| 7 | | agencies and departments shall provide the Illinois Department |
| 8 | | access to confidential and other information and data necessary |
| 9 | | to perform eligibility and payment verifications and other |
| 10 | | Illinois Department functions. This includes, but is not |
| 11 | | limited to: information pertaining to licensure; |
| 12 | | certification; earnings; immigration status; citizenship; wage |
| 13 | | reporting; unearned and earned income; pension income; |
| 14 | | employment; supplemental security income; social security |
| 15 | | numbers; National Provider Identifier (NPI) numbers; the |
| 16 | | National Practitioner Data Bank (NPDB); program and agency |
| 17 | | exclusions; taxpayer identification numbers; tax delinquency; |
| 18 | | corporate information; and death records. |
| 19 | | The Illinois Department shall enter into agreements with |
| 20 | | State agencies and departments, and is authorized to enter into |
| 21 | | agreements with federal agencies and departments, under which |
| 22 | | such agencies and departments shall share data necessary for |
| 23 | | medical assistance program integrity functions and oversight. |
| 24 | | The Illinois Department shall develop, in cooperation with |
| 25 | | other State departments and agencies, and in compliance with |
| 26 | | applicable federal laws and regulations, appropriate and |
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| 1 | | effective methods to share such data. At a minimum, and to the |
| 2 | | extent necessary to provide data sharing, the Illinois |
| 3 | | Department shall enter into agreements with State agencies and |
| 4 | | departments, and is authorized to enter into agreements with |
| 5 | | federal agencies and departments, including but not limited to: |
| 6 | | the Secretary of State; the Department of Revenue; the |
| 7 | | Department of Public Health; the Department of Human Services; |
| 8 | | and the Department of Financial and Professional Regulation. |
| 9 | | Beginning in fiscal year 2013, the Illinois Department |
| 10 | | shall set forth a request for information to identify the |
| 11 | | benefits of a pre-payment, post-adjudication, and post-edit |
| 12 | | claims system with the goals of streamlining claims processing |
| 13 | | and provider reimbursement, reducing the number of pending or |
| 14 | | rejected claims, and helping to ensure a more transparent |
| 15 | | adjudication process through the utilization of: (i) provider |
| 16 | | data verification and provider screening technology; and (ii) |
| 17 | | clinical code editing; and (iii) pre-pay, pre- or |
| 18 | | post-adjudicated predictive modeling with an integrated case |
| 19 | | management system with link analysis. Such a request for |
| 20 | | information shall not be considered as a request for proposal |
| 21 | | or as an obligation on the part of the Illinois Department to |
| 22 | | take any action or acquire any products or services. |
| 23 | | The Illinois Department shall establish policies, |
| 24 | | procedures,
standards and criteria by rule for the acquisition, |
| 25 | | repair and replacement
of orthotic and prosthetic devices and |
| 26 | | durable medical equipment. Such
rules shall provide, but not be |
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| 1 | | limited to, the following services: (1)
immediate repair or |
| 2 | | replacement of such devices by recipients; and (2) rental, |
| 3 | | lease, purchase or lease-purchase of
durable medical equipment |
| 4 | | in a cost-effective manner, taking into
consideration the |
| 5 | | recipient's medical prognosis, the extent of the
recipient's |
| 6 | | needs, and the requirements and costs for maintaining such
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| 7 | | equipment. Subject to prior approval, such rules shall enable a |
| 8 | | recipient to temporarily acquire and
use alternative or |
| 9 | | substitute devices or equipment pending repairs or
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| 10 | | replacements of any device or equipment previously authorized |
| 11 | | for such
recipient by the Department.
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| 12 | | The Department shall execute, relative to the nursing home |
| 13 | | prescreening
project, written inter-agency agreements with the |
| 14 | | Department of Human
Services and the Department on Aging, to |
| 15 | | effect the following: (i) intake
procedures and common |
| 16 | | eligibility criteria for those persons who are receiving
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| 17 | | non-institutional services; and (ii) the establishment and |
| 18 | | development of
non-institutional services in areas of the State |
| 19 | | where they are not currently
available or are undeveloped; and |
| 20 | | (iii) notwithstanding any other provision of law, subject to |
| 21 | | federal approval, on and after July 1, 2012, an increase in the |
| 22 | | determination of need (DON) scores from 29 to 37 for applicants |
| 23 | | for institutional and home and community-based long term care; |
| 24 | | if and only if federal approval is not granted, the Department |
| 25 | | may, in conjunction with other affected agencies, implement |
| 26 | | utilization controls or changes in benefit packages to |
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| 1 | | effectuate a similar savings amount for this population; and |
| 2 | | (iv) no later than July 1, 2013, minimum level of care |
| 3 | | eligibility criteria for institutional and home and |
| 4 | | community-based long term care; and (v) no later than October |
| 5 | | 1, 2013, establish procedures to permit long term care |
| 6 | | providers access to eligibility scores for individuals with an |
| 7 | | admission date who are seeking or receiving services from the |
| 8 | | long term care provider. In order to select the minimum level |
| 9 | | of care eligibility criteria, the Governor shall establish a |
| 10 | | workgroup that includes affected agency representatives and |
| 11 | | stakeholders representing the institutional and home and |
| 12 | | community-based long term care interests. This Section shall |
| 13 | | not restrict the Department from implementing lower level of |
| 14 | | care eligibility criteria for community-based services in |
| 15 | | circumstances where federal approval has been granted.
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| 16 | | The Illinois Department shall develop and operate, in |
| 17 | | cooperation
with other State Departments and agencies and in |
| 18 | | compliance with
applicable federal laws and regulations, |
| 19 | | appropriate and effective
systems of health care evaluation and |
| 20 | | programs for monitoring of
utilization of health care services |
| 21 | | and facilities, as it affects
persons eligible for medical |
| 22 | | assistance under this Code.
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| 23 | | The Illinois Department shall report annually to the |
| 24 | | General Assembly,
no later than the second Friday in April of |
| 25 | | 1979 and each year
thereafter, in regard to:
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| 26 | | (a) actual statistics and trends in utilization of |
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| 1 | | medical services by
public aid recipients;
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| 2 | | (b) actual statistics and trends in the provision of |
| 3 | | the various medical
services by medical vendors;
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| 4 | | (c) current rate structures and proposed changes in |
| 5 | | those rate structures
for the various medical vendors; and
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| 6 | | (d) efforts at utilization review and control by the |
| 7 | | Illinois Department.
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| 8 | | The period covered by each report shall be the 3 years |
| 9 | | ending on the June
30 prior to the report. The report shall |
| 10 | | include suggested legislation
for consideration by the General |
| 11 | | Assembly. The filing of one copy of the
report with the |
| 12 | | Speaker, one copy with the Minority Leader and one copy
with |
| 13 | | the Clerk of the House of Representatives, one copy with the |
| 14 | | President,
one copy with the Minority Leader and one copy with |
| 15 | | the Secretary of the
Senate, one copy with the Legislative |
| 16 | | Research Unit, and such additional
copies
with the State |
| 17 | | Government Report Distribution Center for the General
Assembly |
| 18 | | as is required under paragraph (t) of Section 7 of the State
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| 19 | | Library Act shall be deemed sufficient to comply with this |
| 20 | | Section.
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| 21 | | Rulemaking authority to implement Public Act 95-1045, if |
| 22 | | any, is conditioned on the rules being adopted in accordance |
| 23 | | with all provisions of the Illinois Administrative Procedure |
| 24 | | Act and all rules and procedures of the Joint Committee on |
| 25 | | Administrative Rules; any purported rule not so adopted, for |
| 26 | | whatever reason, is unauthorized. |
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| 1 | | On and after July 1, 2012, the Department shall reduce any |
| 2 | | rate of reimbursement for services or other payments or alter |
| 3 | | any methodologies authorized by this Code to reduce any rate of |
| 4 | | reimbursement for services or other payments in accordance with |
| 5 | | Section 5-5e. |
| 6 | | Because kidney transplantation can be an appropriate, cost |
| 7 | | effective
alternative to renal dialysis when medically |
| 8 | | necessary and notwithstanding the provisions of Section 1-11 of |
| 9 | | this Code, beginning October 1, 2014, the Department shall |
| 10 | | cover kidney transplantation for noncitizens with end-stage |
| 11 | | renal disease who are not eligible for comprehensive medical |
| 12 | | benefits, who meet the residency requirements of Section 5-3 of |
| 13 | | this Code, and who would otherwise meet the financial |
| 14 | | requirements of the appropriate class of eligible persons under |
| 15 | | Section 5-2 of this Code. To qualify for coverage of kidney |
| 16 | | transplantation, such person must be receiving emergency renal |
| 17 | | dialysis services covered by the Department. Providers under |
| 18 | | this Section shall be prior approved and certified by the |
| 19 | | Department to perform kidney transplantation and the services |
| 20 | | under this Section shall be limited to services associated with |
| 21 | | kidney transplantation. |
| 22 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; |
| 23 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. |
| 24 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, |
| 25 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; |
| 26 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff. |
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| 1 | | 8-21-15; revised 8-31-15.)
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| 2 | | (Text of Section after amendment by P.A. 99-407) |
| 3 | | Sec. 5-5. Medical services. The Illinois Department, by |
| 4 | | rule, shall
determine the quantity and quality of and the rate |
| 5 | | of reimbursement for the
medical assistance for which
payment |
| 6 | | will be authorized, and the medical services to be provided,
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| 7 | | which may include all or part of the following: (1) inpatient |
| 8 | | hospital
services; (2) outpatient hospital services; (3) other |
| 9 | | laboratory and
X-ray services; (4) skilled nursing home |
| 10 | | services; (5) physicians'
services whether furnished in the |
| 11 | | office, the patient's home, a
hospital, a skilled nursing home, |
| 12 | | or elsewhere; (6) medical care, or any
other type of remedial |
| 13 | | care furnished by licensed practitioners, including the |
| 14 | | services of certified professional midwives licensed pursuant |
| 15 | | to the Home Birth Safety Act; (7)
home health care services; |
| 16 | | (8) private duty nursing service; (9) clinic
services; (10) |
| 17 | | dental services, including prevention and treatment of |
| 18 | | periodontal disease and dental caries disease for pregnant |
| 19 | | women, provided by an individual licensed to practice dentistry |
| 20 | | or dental surgery; for purposes of this item (10), "dental |
| 21 | | services" means diagnostic, preventive, or corrective |
| 22 | | procedures provided by or under the supervision of a dentist in |
| 23 | | the practice of his or her profession; (11) physical therapy |
| 24 | | and related
services; (12) prescribed drugs, dentures, and |
| 25 | | prosthetic devices; and
eyeglasses prescribed by a physician |
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| 1 | | skilled in the diseases of the eye,
or by an optometrist, |
| 2 | | whichever the person may select; (13) other
diagnostic, |
| 3 | | screening, preventive, and rehabilitative services, including |
| 4 | | to ensure that the individual's need for intervention or |
| 5 | | treatment of mental disorders or substance use disorders or |
| 6 | | co-occurring mental health and substance use disorders is |
| 7 | | determined using a uniform screening, assessment, and |
| 8 | | evaluation process inclusive of criteria, for children and |
| 9 | | adults; for purposes of this item (13), a uniform screening, |
| 10 | | assessment, and evaluation process refers to a process that |
| 11 | | includes an appropriate evaluation and, as warranted, a |
| 12 | | referral; "uniform" does not mean the use of a singular |
| 13 | | instrument, tool, or process that all must utilize; (14)
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| 14 | | transportation and such other expenses as may be necessary; |
| 15 | | (15) medical
treatment of sexual assault survivors, as defined |
| 16 | | in
Section 1a of the Sexual Assault Survivors Emergency |
| 17 | | Treatment Act, for
injuries sustained as a result of the sexual |
| 18 | | assault, including
examinations and laboratory tests to |
| 19 | | discover evidence which may be used in
criminal proceedings |
| 20 | | arising from the sexual assault; (16) the
diagnosis and |
| 21 | | treatment of sickle cell anemia; and (17)
any other medical |
| 22 | | care, and any other type of remedial care recognized
under the |
| 23 | | laws of this State, but not including abortions, or induced
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| 24 | | miscarriages or premature births, unless, in the opinion of a |
| 25 | | physician,
such procedures are necessary for the preservation |
| 26 | | of the life of the
woman seeking such treatment, or except an |
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| 1 | | induced premature birth
intended to produce a live viable child |
| 2 | | and such procedure is necessary
for the health of the mother or |
| 3 | | her unborn child. The Illinois Department,
by rule, shall |
| 4 | | prohibit any physician from providing medical assistance
to |
| 5 | | anyone eligible therefor under this Code where such physician |
| 6 | | has been
found guilty of performing an abortion procedure in a |
| 7 | | wilful and wanton
manner upon a woman who was not pregnant at |
| 8 | | the time such abortion
procedure was performed. The term "any |
| 9 | | other type of remedial care" shall
include nursing care and |
| 10 | | nursing home service for persons who rely on
treatment by |
| 11 | | spiritual means alone through prayer for healing.
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| 12 | | Notwithstanding any other provision of this Section, a |
| 13 | | comprehensive
tobacco use cessation program that includes |
| 14 | | purchasing prescription drugs or
prescription medical devices |
| 15 | | approved by the Food and Drug Administration shall
be covered |
| 16 | | under the medical assistance
program under this Article for |
| 17 | | persons who are otherwise eligible for
assistance under this |
| 18 | | Article.
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| 19 | | Notwithstanding any other provision of this Code, the |
| 20 | | Illinois
Department may not require, as a condition of payment |
| 21 | | for any laboratory
test authorized under this Article, that a |
| 22 | | physician's handwritten signature
appear on the laboratory |
| 23 | | test order form. The Illinois Department may,
however, impose |
| 24 | | other appropriate requirements regarding laboratory test
order |
| 25 | | documentation.
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| 26 | | Upon receipt of federal approval of an amendment to the |
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| 1 | | Illinois Title XIX State Plan for this purpose, the Department |
| 2 | | shall authorize the Chicago Public Schools (CPS) to procure a |
| 3 | | vendor or vendors to manufacture eyeglasses for individuals |
| 4 | | enrolled in a school within the CPS system. CPS shall ensure |
| 5 | | that its vendor or vendors are enrolled as providers in the |
| 6 | | medical assistance program and in any capitated Medicaid |
| 7 | | managed care entity (MCE) serving individuals enrolled in a |
| 8 | | school within the CPS system. Under any contract procured under |
| 9 | | this provision, the vendor or vendors must serve only |
| 10 | | individuals enrolled in a school within the CPS system. Claims |
| 11 | | for services provided by CPS's vendor or vendors to recipients |
| 12 | | of benefits in the medical assistance program under this Code, |
| 13 | | the Children's Health Insurance Program, or the Covering ALL |
| 14 | | KIDS Health Insurance Program shall be submitted to the |
| 15 | | Department or the MCE in which the individual is enrolled for |
| 16 | | payment and shall be reimbursed at the Department's or the |
| 17 | | MCE's established rates or rate methodologies for eyeglasses. |
| 18 | | On and after July 1, 2012, the Department of Healthcare and |
| 19 | | Family Services may provide the following services to
persons
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| 20 | | eligible for assistance under this Article who are |
| 21 | | participating in
education, training or employment programs |
| 22 | | operated by the Department of Human
Services as successor to |
| 23 | | the Department of Public Aid:
|
| 24 | | (1) dental services provided by or under the |
| 25 | | supervision of a dentist; and
|
| 26 | | (2) eyeglasses prescribed by a physician skilled in the |
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| 1 | | diseases of the
eye, or by an optometrist, whichever the |
| 2 | | person may select.
|
| 3 | | Notwithstanding any other provision of this Code and |
| 4 | | subject to federal approval, the Department may adopt rules to |
| 5 | | allow a dentist who is volunteering his or her service at no |
| 6 | | cost to render dental services through an enrolled |
| 7 | | not-for-profit health clinic without the dentist personally |
| 8 | | enrolling as a participating provider in the medical assistance |
| 9 | | program. A not-for-profit health clinic shall include a public |
| 10 | | health clinic or Federally Qualified Health Center or other |
| 11 | | enrolled provider, as determined by the Department, through |
| 12 | | which dental services covered under this Section are performed. |
| 13 | | The Department shall establish a process for payment of claims |
| 14 | | for reimbursement for covered dental services rendered under |
| 15 | | this provision. |
| 16 | | The Illinois Department, by rule, may distinguish and |
| 17 | | classify the
medical services to be provided only in accordance |
| 18 | | with the classes of
persons designated in Section 5-2.
|
| 19 | | The Department of Healthcare and Family Services must |
| 20 | | provide coverage and reimbursement for amino acid-based |
| 21 | | elemental formulas, regardless of delivery method, for the |
| 22 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
| 23 | | short bowel syndrome when the prescribing physician has issued |
| 24 | | a written order stating that the amino acid-based elemental |
| 25 | | formula is medically necessary.
|
| 26 | | The Illinois Department shall authorize the provision of, |
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| 1 | | and shall
authorize payment for, screening by low-dose |
| 2 | | mammography for the presence of
occult breast cancer for women |
| 3 | | 35 years of age or older who are eligible
for medical |
| 4 | | assistance under this Article, as follows: |
| 5 | | (A) A baseline
mammogram for women 35 to 39 years of |
| 6 | | age.
|
| 7 | | (B) An annual mammogram for women 40 years of age or |
| 8 | | older. |
| 9 | | (C) A mammogram at the age and intervals considered |
| 10 | | medically necessary by the woman's health care provider for |
| 11 | | women under 40 years of age and having a family history of |
| 12 | | breast cancer, prior personal history of breast cancer, |
| 13 | | positive genetic testing, or other risk factors. |
| 14 | | (D) A comprehensive ultrasound screening of an entire |
| 15 | | breast or breasts if a mammogram demonstrates |
| 16 | | heterogeneous or dense breast tissue, when medically |
| 17 | | necessary as determined by a physician licensed to practice |
| 18 | | medicine in all of its branches. |
| 19 | | (E) A screening MRI when medically necessary, as |
| 20 | | determined by a physician licensed to practice medicine in |
| 21 | | all of its branches. |
| 22 | | All screenings
shall
include a physical breast exam, |
| 23 | | instruction on self-examination and
information regarding the |
| 24 | | frequency of self-examination and its value as a
preventative |
| 25 | | tool. For purposes of this Section, "low-dose mammography" |
| 26 | | means
the x-ray examination of the breast using equipment |
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| 1 | | dedicated specifically
for mammography, including the x-ray |
| 2 | | tube, filter, compression device,
and image receptor, with an |
| 3 | | average radiation exposure delivery
of less than one rad per |
| 4 | | breast for 2 views of an average size breast.
The term also |
| 5 | | includes digital mammography and includes breast |
| 6 | | tomosynthesis. As used in this Section, the term "breast |
| 7 | | tomosynthesis" means a radiologic procedure that involves the |
| 8 | | acquisition of projection images over the stationary breast to |
| 9 | | produce cross-sectional digital three-dimensional images of |
| 10 | | the breast.
|
| 11 | | On and after January 1, 2016, the Department shall ensure |
| 12 | | that all networks of care for adult clients of the Department |
| 13 | | include access to at least one breast imaging Center of Imaging |
| 14 | | Excellence as certified by the American College of Radiology. |
| 15 | | On and after January 1, 2012, providers participating in a |
| 16 | | quality improvement program approved by the Department shall be |
| 17 | | reimbursed for screening and diagnostic mammography at the same |
| 18 | | rate as the Medicare program's rates, including the increased |
| 19 | | reimbursement for digital mammography. |
| 20 | | The Department shall convene an expert panel including |
| 21 | | representatives of hospitals, free-standing mammography |
| 22 | | facilities, and doctors, including radiologists, to establish |
| 23 | | quality standards for mammography. |
| 24 | | On and after January 1, 2017, providers participating in a |
| 25 | | breast cancer treatment quality improvement program approved |
| 26 | | by the Department shall be reimbursed for breast cancer |
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| 1 | | treatment at a rate that is no lower than 95% of the Medicare |
| 2 | | program's rates for the data elements included in the breast |
| 3 | | cancer treatment quality program. |
| 4 | | The Department shall convene an expert panel, including |
| 5 | | representatives of hospitals, free standing breast cancer |
| 6 | | treatment centers, breast cancer quality organizations, and |
| 7 | | doctors, including breast surgeons, reconstructive breast |
| 8 | | surgeons, oncologists, and primary care providers to establish |
| 9 | | quality standards for breast cancer treatment. |
| 10 | | Subject to federal approval, the Department shall |
| 11 | | establish a rate methodology for mammography at federally |
| 12 | | qualified health centers and other encounter-rate clinics. |
| 13 | | These clinics or centers may also collaborate with other |
| 14 | | hospital-based mammography facilities. By January 1, 2016, the |
| 15 | | Department shall report to the General Assembly on the status |
| 16 | | of the provision set forth in this paragraph. |
| 17 | | The Department shall establish a methodology to remind |
| 18 | | women who are age-appropriate for screening mammography, but |
| 19 | | who have not received a mammogram within the previous 18 |
| 20 | | months, of the importance and benefit of screening mammography. |
| 21 | | The Department shall work with experts in breast cancer |
| 22 | | outreach and patient navigation to optimize these reminders and |
| 23 | | shall establish a methodology for evaluating their |
| 24 | | effectiveness and modifying the methodology based on the |
| 25 | | evaluation. |
| 26 | | The Department shall establish a performance goal for |
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| 1 | | primary care providers with respect to their female patients |
| 2 | | over age 40 receiving an annual mammogram. This performance |
| 3 | | goal shall be used to provide additional reimbursement in the |
| 4 | | form of a quality performance bonus to primary care providers |
| 5 | | who meet that goal. |
| 6 | | The Department shall devise a means of case-managing or |
| 7 | | patient navigation for beneficiaries diagnosed with breast |
| 8 | | cancer. This program shall initially operate as a pilot program |
| 9 | | in areas of the State with the highest incidence of mortality |
| 10 | | related to breast cancer. At least one pilot program site shall |
| 11 | | be in the metropolitan Chicago area and at least one site shall |
| 12 | | be outside the metropolitan Chicago area. On or after July 1, |
| 13 | | 2016, the pilot program shall be expanded to include one site |
| 14 | | in western Illinois, one site in southern Illinois, one site in |
| 15 | | central Illinois, and 4 sites within metropolitan Chicago. An |
| 16 | | evaluation of the pilot program shall be carried out measuring |
| 17 | | health outcomes and cost of care for those served by the pilot |
| 18 | | program compared to similarly situated patients who are not |
| 19 | | served by the pilot program. |
| 20 | | The Department shall require all networks of care to |
| 21 | | develop a means either internally or by contract with experts |
| 22 | | in navigation and community outreach to navigate cancer |
| 23 | | patients to comprehensive care in a timely fashion. The |
| 24 | | Department shall require all networks of care to include access |
| 25 | | for patients diagnosed with cancer to at least one academic |
| 26 | | commission on cancer-accredited cancer program as an |
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| 1 | | in-network covered benefit. |
| 2 | | Any medical or health care provider shall immediately |
| 3 | | recommend, to
any pregnant woman who is being provided prenatal |
| 4 | | services and is suspected
of drug abuse or is addicted as |
| 5 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
| 6 | | Act, referral to a local substance abuse treatment provider
|
| 7 | | licensed by the Department of Human Services or to a licensed
|
| 8 | | hospital which provides substance abuse treatment services. |
| 9 | | The Department of Healthcare and Family Services
shall assure |
| 10 | | coverage for the cost of treatment of the drug abuse or
|
| 11 | | addiction for pregnant recipients in accordance with the |
| 12 | | Illinois Medicaid
Program in conjunction with the Department of |
| 13 | | Human Services.
|
| 14 | | All medical providers providing medical assistance to |
| 15 | | pregnant women
under this Code shall receive information from |
| 16 | | the Department on the
availability of services under the Drug |
| 17 | | Free Families with a Future or any
comparable program providing |
| 18 | | case management services for addicted women,
including |
| 19 | | information on appropriate referrals for other social services
|
| 20 | | that may be needed by addicted women in addition to treatment |
| 21 | | for addiction.
|
| 22 | | The Illinois Department, in cooperation with the |
| 23 | | Departments of Human
Services (as successor to the Department |
| 24 | | of Alcoholism and Substance
Abuse) and Public Health, through a |
| 25 | | public awareness campaign, may
provide information concerning |
| 26 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
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| 1 | | health care, and other pertinent programs directed at
reducing |
| 2 | | the number of drug-affected infants born to recipients of |
| 3 | | medical
assistance.
|
| 4 | | Neither the Department of Healthcare and Family Services |
| 5 | | nor the Department of Human
Services shall sanction the |
| 6 | | recipient solely on the basis of
her substance abuse.
|
| 7 | | The Illinois Department shall establish such regulations |
| 8 | | governing
the dispensing of health services under this Article |
| 9 | | as it shall deem
appropriate. The Department
should
seek the |
| 10 | | advice of formal professional advisory committees appointed by
|
| 11 | | the Director of the Illinois Department for the purpose of |
| 12 | | providing regular
advice on policy and administrative matters, |
| 13 | | information dissemination and
educational activities for |
| 14 | | medical and health care providers, and
consistency in |
| 15 | | procedures to the Illinois Department.
|
| 16 | | The Illinois Department may develop and contract with |
| 17 | | Partnerships of
medical providers to arrange medical services |
| 18 | | for persons eligible under
Section 5-2 of this Code. |
| 19 | | Implementation of this Section may be by
demonstration projects |
| 20 | | in certain geographic areas. The Partnership shall
be |
| 21 | | represented by a sponsor organization. The Department, by rule, |
| 22 | | shall
develop qualifications for sponsors of Partnerships. |
| 23 | | Nothing in this
Section shall be construed to require that the |
| 24 | | sponsor organization be a
medical organization.
|
| 25 | | The sponsor must negotiate formal written contracts with |
| 26 | | medical
providers for physician services, inpatient and |
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| 1 | | outpatient hospital care,
home health services, treatment for |
| 2 | | alcoholism and substance abuse, and
other services determined |
| 3 | | necessary by the Illinois Department by rule for
delivery by |
| 4 | | Partnerships. Physician services must include prenatal and
|
| 5 | | obstetrical care. The Illinois Department shall reimburse |
| 6 | | medical services
delivered by Partnership providers to clients |
| 7 | | in target areas according to
provisions of this Article and the |
| 8 | | Illinois Health Finance Reform Act,
except that:
|
| 9 | | (1) Physicians participating in a Partnership and |
| 10 | | providing certain
services, which shall be determined by |
| 11 | | the Illinois Department, to persons
in areas covered by the |
| 12 | | Partnership may receive an additional surcharge
for such |
| 13 | | services.
|
| 14 | | (2) The Department may elect to consider and negotiate |
| 15 | | financial
incentives to encourage the development of |
| 16 | | Partnerships and the efficient
delivery of medical care.
|
| 17 | | (3) Persons receiving medical services through |
| 18 | | Partnerships may receive
medical and case management |
| 19 | | services above the level usually offered
through the |
| 20 | | medical assistance program.
|
| 21 | | Medical providers shall be required to meet certain |
| 22 | | qualifications to
participate in Partnerships to ensure the |
| 23 | | delivery of high quality medical
services. These |
| 24 | | qualifications shall be determined by rule of the Illinois
|
| 25 | | Department and may be higher than qualifications for |
| 26 | | participation in the
medical assistance program. Partnership |
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| 1 | | sponsors may prescribe reasonable
additional qualifications |
| 2 | | for participation by medical providers, only with
the prior |
| 3 | | written approval of the Illinois Department.
|
| 4 | | Nothing in this Section shall limit the free choice of |
| 5 | | practitioners,
hospitals, and other providers of medical |
| 6 | | services by clients.
In order to ensure patient freedom of |
| 7 | | choice, the Illinois Department shall
immediately promulgate |
| 8 | | all rules and take all other necessary actions so that
provided |
| 9 | | services may be accessed from therapeutically certified |
| 10 | | optometrists
to the full extent of the Illinois Optometric |
| 11 | | Practice Act of 1987 without
discriminating between service |
| 12 | | providers.
|
| 13 | | The Department shall apply for a waiver from the United |
| 14 | | States Health
Care Financing Administration to allow for the |
| 15 | | implementation of
Partnerships under this Section.
|
| 16 | | The Illinois Department shall require health care |
| 17 | | providers to maintain
records that document the medical care |
| 18 | | and services provided to recipients
of Medical Assistance under |
| 19 | | this Article. Such records must be retained for a period of not |
| 20 | | less than 6 years from the date of service or as provided by |
| 21 | | applicable State law, whichever period is longer, except that |
| 22 | | if an audit is initiated within the required retention period |
| 23 | | then the records must be retained until the audit is completed |
| 24 | | and every exception is resolved. The Illinois Department shall
|
| 25 | | require health care providers to make available, when |
| 26 | | authorized by the
patient, in writing, the medical records in a |
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| 1 | | timely fashion to other
health care providers who are treating |
| 2 | | or serving persons eligible for
Medical Assistance under this |
| 3 | | Article. All dispensers of medical services
shall be required |
| 4 | | to maintain and retain business and professional records
|
| 5 | | sufficient to fully and accurately document the nature, scope, |
| 6 | | details and
receipt of the health care provided to persons |
| 7 | | eligible for medical
assistance under this Code, in accordance |
| 8 | | with regulations promulgated by
the Illinois Department. The |
| 9 | | rules and regulations shall require that proof
of the receipt |
| 10 | | of prescription drugs, dentures, prosthetic devices and
|
| 11 | | eyeglasses by eligible persons under this Section accompany |
| 12 | | each claim
for reimbursement submitted by the dispenser of such |
| 13 | | medical services.
No such claims for reimbursement shall be |
| 14 | | approved for payment by the Illinois
Department without such |
| 15 | | proof of receipt, unless the Illinois Department
shall have put |
| 16 | | into effect and shall be operating a system of post-payment
|
| 17 | | audit and review which shall, on a sampling basis, be deemed |
| 18 | | adequate by
the Illinois Department to assure that such drugs, |
| 19 | | dentures, prosthetic
devices and eyeglasses for which payment |
| 20 | | is being made are actually being
received by eligible |
| 21 | | recipients. Within 90 days after the effective date of
this |
| 22 | | amendatory Act of 1984, the Illinois Department shall establish |
| 23 | | a
current list of acquisition costs for all prosthetic devices |
| 24 | | and any
other items recognized as medical equipment and |
| 25 | | supplies reimbursable under
this Article and shall update such |
| 26 | | list on a quarterly basis, except that
the acquisition costs of |
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| 1 | | all prescription drugs shall be updated no
less frequently than |
| 2 | | every 30 days as required by Section 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
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| 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
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| 7 | | replacements of any device or equipment previously authorized |
| 8 | | for such
recipient by the Department.
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| 9 | | The Department shall execute, relative to the nursing home |
| 10 | | prescreening
project, written inter-agency agreements with the |
| 11 | | Department of Human
Services and the Department on Aging, to |
| 12 | | effect the following: (i) intake
procedures and common |
| 13 | | eligibility criteria for those persons who are receiving
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| 14 | | non-institutional services; and (ii) the establishment and |
| 15 | | development of
non-institutional services in areas of the State |
| 16 | | where they are not currently
available or are undeveloped; and |
| 17 | | (iii) notwithstanding any other provision of law, subject to |
| 18 | | federal approval, on and after July 1, 2012, an increase in the |
| 19 | | determination of need (DON) scores from 29 to 37 for applicants |
| 20 | | for institutional and home and community-based long term care; |
| 21 | | if and only if federal approval is not granted, the Department |
| 22 | | may, in conjunction with other affected agencies, implement |
| 23 | | utilization controls or changes in benefit packages to |
| 24 | | effectuate a similar savings amount for this population; and |
| 25 | | (iv) no later than July 1, 2013, minimum level of care |
| 26 | | eligibility criteria for institutional and home and |
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| 1 | | community-based long term care; and (v) no later than October |
| 2 | | 1, 2013, establish procedures to permit long term care |
| 3 | | providers access to eligibility scores for individuals with an |
| 4 | | admission date who are seeking or receiving services from the |
| 5 | | long term care provider. In order to select the minimum level |
| 6 | | of care eligibility criteria, the Governor shall establish a |
| 7 | | workgroup that includes affected agency representatives and |
| 8 | | stakeholders representing the institutional and home and |
| 9 | | community-based long term care interests. This Section shall |
| 10 | | not restrict the Department from implementing lower level of |
| 11 | | care eligibility criteria for community-based services in |
| 12 | | circumstances where federal approval has been granted.
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| 13 | | The Illinois Department shall develop and operate, in |
| 14 | | cooperation
with other State Departments and agencies and in |
| 15 | | compliance with
applicable federal laws and regulations, |
| 16 | | appropriate and effective
systems of health care evaluation and |
| 17 | | programs for monitoring of
utilization of health care services |
| 18 | | and facilities, as it affects
persons eligible for medical |
| 19 | | assistance under this Code.
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| 20 | | The Illinois Department shall report annually to the |
| 21 | | General Assembly,
no later than the second Friday in April of |
| 22 | | 1979 and each year
thereafter, in regard to:
|
| 23 | | (a) actual statistics and trends in utilization of |
| 24 | | medical services by
public aid recipients;
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| 25 | | (b) actual statistics and trends in the provision of |
| 26 | | the various medical
services by medical vendors;
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| 1 | | (c) current rate structures and proposed changes in |
| 2 | | those rate structures
for the various medical vendors; and
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| 3 | | (d) efforts at utilization review and control by the |
| 4 | | Illinois Department.
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| 5 | | The period covered by each report shall be the 3 years |
| 6 | | ending on the June
30 prior to the report. The report shall |
| 7 | | include suggested legislation
for consideration by the General |
| 8 | | Assembly. The filing of one copy of the
report with the |
| 9 | | Speaker, one copy with the Minority Leader and one copy
with |
| 10 | | the Clerk of the House of Representatives, one copy with the |
| 11 | | President,
one copy with the Minority Leader and one copy with |
| 12 | | the Secretary of the
Senate, one copy with the Legislative |
| 13 | | Research Unit, and such additional
copies
with the State |
| 14 | | Government Report Distribution Center for the General
Assembly |
| 15 | | as is required under paragraph (t) of Section 7 of the State
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| 16 | | Library Act shall be deemed sufficient to comply with this |
| 17 | | Section.
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| 18 | | Rulemaking authority to implement Public Act 95-1045, if |
| 19 | | any, is conditioned on the rules being adopted in accordance |
| 20 | | with all provisions of the Illinois Administrative Procedure |
| 21 | | Act and all rules and procedures of the Joint Committee on |
| 22 | | Administrative Rules; any purported rule not so adopted, for |
| 23 | | whatever reason, is unauthorized. |
| 24 | | On and after July 1, 2012, the Department shall reduce any |
| 25 | | rate of reimbursement for services or other payments or alter |
| 26 | | any methodologies authorized by this Code to reduce any rate of |
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| 1 | | reimbursement for services or other payments in accordance with |
| 2 | | Section 5-5e. |
| 3 | | Because kidney transplantation can be an appropriate, cost |
| 4 | | effective
alternative to renal dialysis when medically |
| 5 | | necessary and notwithstanding the provisions of Section 1-11 of |
| 6 | | this Code, beginning October 1, 2014, the Department shall |
| 7 | | cover kidney transplantation for noncitizens with end-stage |
| 8 | | renal disease who are not eligible for comprehensive medical |
| 9 | | benefits, who meet the residency requirements of Section 5-3 of |
| 10 | | this Code, and who would otherwise meet the financial |
| 11 | | requirements of the appropriate class of eligible persons under |
| 12 | | Section 5-2 of this Code. To qualify for coverage of kidney |
| 13 | | transplantation, such person must be receiving emergency renal |
| 14 | | dialysis services covered by the Department. Providers under |
| 15 | | this Section shall be prior approved and certified by the |
| 16 | | Department to perform kidney transplantation and the services |
| 17 | | under this Section shall be limited to services associated with |
| 18 | | kidney transplantation. |
| 19 | | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; |
| 20 | | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. |
| 21 | | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, |
| 22 | | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; |
| 23 | | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section |
| 24 | | 99 of P.A. 99-407 for its effective date); 99-433, eff. |
| 25 | | 8-21-15; revised 8-31-15.)
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