Bill Text: IL HB4635 | 2013-2014 | 98th General Assembly | Introduced
Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to provide medical assistance coverage for diabetes education provided by a certified diabetes education provider for children with Type 1 diabetes who are under the age of 18. Defines "certified diabetes education provider" to mean a professional who has undergone training and certification under conditions approved by the American Association of Diabetes Educators or a successor association of professionals. Defines "Type 1 diabetes" to have the same meaning ascribed to it by the American Diabetes Association or any successor association. Effective immediately.
Spectrum: Bipartisan Bill
Status: (Failed) 2014-12-03 - Session Sine Die [HB4635 Detail]
Download: Illinois-2013-HB4635-Introduced.html
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1 | AN ACT concerning public aid.
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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 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||
5 | changing Section 5-5 as follows:
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6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||||||||||||||||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||||||||||||||||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||||||||||||||||||||
10 | will be authorized, and the medical services to be provided,
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11 | which may include all or part of the following: (1) inpatient | ||||||||||||||||||||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||||||||||||||||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||||||||||||||||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||||||||||||||||||||
15 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||||||||||||||||||||
16 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||||||||||||||||||||
17 | care furnished by licensed practitioners; (7)
home health care | ||||||||||||||||||||||||
18 | services; (8) private duty nursing service; (9) clinic
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19 | services; (10) dental services, including prevention and | ||||||||||||||||||||||||
20 | treatment of periodontal disease and dental caries disease for | ||||||||||||||||||||||||
21 | pregnant women, provided by an individual licensed to practice | ||||||||||||||||||||||||
22 | dentistry or dental surgery; for purposes of this item (10), | ||||||||||||||||||||||||
23 | "dental services" means diagnostic, preventive, or corrective |
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1 | procedures provided by or under the supervision of a dentist in | ||||||
2 | the practice of his or her profession; (11) physical therapy | ||||||
3 | and related
services; (12) prescribed drugs, dentures, and | ||||||
4 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
5 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
6 | whichever the person may select; (13) other
diagnostic, | ||||||
7 | screening, preventive, and rehabilitative services, including | ||||||
8 | to ensure that the individual's need for intervention or | ||||||
9 | treatment of mental disorders or substance use disorders or | ||||||
10 | co-occurring mental health and substance use disorders is | ||||||
11 | determined using a uniform screening, assessment, and | ||||||
12 | evaluation process inclusive of criteria, for children and | ||||||
13 | adults; for purposes of this item (13), a uniform screening, | ||||||
14 | assessment, and evaluation process refers to a process that | ||||||
15 | includes an appropriate evaluation and, as warranted, a | ||||||
16 | referral; "uniform" does not mean the use of a singular | ||||||
17 | instrument, tool, or process that all must utilize; (14)
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18 | transportation and such other expenses as may be necessary; | ||||||
19 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
20 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
21 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
22 | assault, including
examinations and laboratory tests to | ||||||
23 | discover evidence which may be used in
criminal proceedings | ||||||
24 | arising from the sexual assault; (16) the
diagnosis and | ||||||
25 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
26 | care, and any other type of remedial care recognized
under the |
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1 | laws of this State, but not including abortions, or induced
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2 | miscarriages or premature births, unless, in the opinion of a | ||||||
3 | physician,
such procedures are necessary for the preservation | ||||||
4 | of the life of the
woman seeking such treatment, or except an | ||||||
5 | induced premature birth
intended to produce a live viable child | ||||||
6 | and such procedure is necessary
for the health of the mother or | ||||||
7 | her unborn child. The Illinois Department,
by rule, shall | ||||||
8 | prohibit any physician from providing medical assistance
to | ||||||
9 | anyone eligible therefor under this Code where such physician | ||||||
10 | has been
found guilty of performing an abortion procedure in a | ||||||
11 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
12 | the time such abortion
procedure was performed. The term "any | ||||||
13 | other type of remedial care" shall
include nursing care and | ||||||
14 | nursing home service for persons who rely on
treatment by | ||||||
15 | spiritual means alone through prayer for healing.
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16 | Notwithstanding any other provision of this Section, a | ||||||
17 | comprehensive
tobacco use cessation program that includes | ||||||
18 | purchasing prescription drugs or
prescription medical devices | ||||||
19 | approved by the Food and Drug Administration shall
be covered | ||||||
20 | under the medical assistance
program under this Article for | ||||||
21 | persons who are otherwise eligible for
assistance under this | ||||||
22 | Article.
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23 | Notwithstanding any other provision of this Code, the | ||||||
24 | Illinois
Department may not require, as a condition of payment | ||||||
25 | for any laboratory
test authorized under this Article, that a | ||||||
26 | physician's handwritten signature
appear on the laboratory |
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1 | test order form. The Illinois Department may,
however, impose | ||||||
2 | other appropriate requirements regarding laboratory test
order | ||||||
3 | documentation.
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4 | Notwithstanding any other provision of this Code, the | ||||||
5 | Department shall provide medical assistance coverage for | ||||||
6 | diabetes education provided by a certified diabetes education | ||||||
7 | provider for children with Type 1 diabetes who are under the | ||||||
8 | age of 18. For purposes of this paragraph: | ||||||
9 | "Certified diabetes education provider" means a | ||||||
10 | professional who has undergone training and certification | ||||||
11 | under conditions approved by the American Association of | ||||||
12 | Diabetes Educators or a successor association of | ||||||
13 | professionals. | ||||||
14 | "Type 1 diabetes" shall have the same meaning ascribed | ||||||
15 | to it by the American Diabetes Association or any successor | ||||||
16 | association. | ||||||
17 | On and after July 1, 2012, the Department of Healthcare and | ||||||
18 | Family Services may provide the following services to
persons
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19 | eligible for assistance under this Article who are | ||||||
20 | participating in
education, training or employment programs | ||||||
21 | operated by the Department of Human
Services as successor to | ||||||
22 | the Department of Public Aid:
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23 | (1) dental services provided by or under the | ||||||
24 | supervision of a dentist; and
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25 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
26 | diseases of the
eye, or by an optometrist, whichever the |
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1 | person may select.
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2 | Notwithstanding any other provision of this Code and | ||||||
3 | subject to federal approval, the Department may adopt rules to | ||||||
4 | allow a dentist who is volunteering his or her service at no | ||||||
5 | cost to render dental services through an enrolled | ||||||
6 | not-for-profit health clinic without the dentist personally | ||||||
7 | enrolling as a participating provider in the medical assistance | ||||||
8 | program. A not-for-profit health clinic shall include a public | ||||||
9 | health clinic or Federally Qualified Health Center or other | ||||||
10 | enrolled provider, as determined by the Department, through | ||||||
11 | which dental services covered under this Section are performed. | ||||||
12 | The Department shall establish a process for payment of claims | ||||||
13 | for reimbursement for covered dental services rendered under | ||||||
14 | this provision. | ||||||
15 | The Illinois Department, by rule, may distinguish and | ||||||
16 | classify the
medical services to be provided only in accordance | ||||||
17 | with the classes of
persons designated in Section 5-2.
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18 | The Department of Healthcare and Family Services must | ||||||
19 | provide coverage and reimbursement for amino acid-based | ||||||
20 | elemental formulas, regardless of delivery method, for the | ||||||
21 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
22 | short bowel syndrome when the prescribing physician has issued | ||||||
23 | a written order stating that the amino acid-based elemental | ||||||
24 | formula is medically necessary.
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25 | The Illinois Department shall authorize the provision of, | ||||||
26 | and shall
authorize payment for, screening by low-dose |
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1 | mammography for the presence of
occult breast cancer for women | ||||||
2 | 35 years of age or older who are eligible
for medical | ||||||
3 | assistance under this Article, as follows: | ||||||
4 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
5 | age.
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6 | (B) An annual mammogram for women 40 years of age or | ||||||
7 | older. | ||||||
8 | (C) A mammogram at the age and intervals considered | ||||||
9 | medically necessary by the woman's health care provider for | ||||||
10 | women under 40 years of age and having a family history of | ||||||
11 | breast cancer, prior personal history of breast cancer, | ||||||
12 | positive genetic testing, or other risk factors. | ||||||
13 | (D) A comprehensive ultrasound screening of an entire | ||||||
14 | breast or breasts if a mammogram demonstrates | ||||||
15 | heterogeneous or dense breast tissue, when medically | ||||||
16 | necessary as determined by a physician licensed to practice | ||||||
17 | medicine in all of its branches. | ||||||
18 | All screenings
shall
include a physical breast exam, | ||||||
19 | instruction on self-examination and
information regarding the | ||||||
20 | frequency of self-examination and its value as a
preventative | ||||||
21 | tool. For purposes of this Section, "low-dose mammography" | ||||||
22 | means
the x-ray examination of the breast using equipment | ||||||
23 | dedicated specifically
for mammography, including the x-ray | ||||||
24 | tube, filter, compression device,
and image receptor, with an | ||||||
25 | average radiation exposure delivery
of less than one rad per | ||||||
26 | breast for 2 views of an average size breast.
The term also |
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1 | includes digital mammography.
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2 | On and after January 1, 2012, providers participating in a | ||||||
3 | quality improvement program approved by the Department shall be | ||||||
4 | reimbursed for screening and diagnostic mammography at the same | ||||||
5 | rate as the Medicare program's rates, including the increased | ||||||
6 | reimbursement for digital mammography. | ||||||
7 | The Department shall convene an expert panel including | ||||||
8 | representatives of hospitals, free-standing mammography | ||||||
9 | facilities, and doctors, including radiologists, to establish | ||||||
10 | quality standards. | ||||||
11 | Subject to federal approval, the Department shall | ||||||
12 | establish a rate methodology for mammography at federally | ||||||
13 | qualified health centers and other encounter-rate clinics. | ||||||
14 | These clinics or centers may also collaborate with other | ||||||
15 | hospital-based mammography facilities. | ||||||
16 | The Department shall establish a methodology to remind | ||||||
17 | women who are age-appropriate for screening mammography, but | ||||||
18 | who have not received a mammogram within the previous 18 | ||||||
19 | months, of the importance and benefit of screening mammography. | ||||||
20 | The Department shall establish a performance goal for | ||||||
21 | primary care providers with respect to their female patients | ||||||
22 | over age 40 receiving an annual mammogram. This performance | ||||||
23 | goal shall be used to provide additional reimbursement in the | ||||||
24 | form of a quality performance bonus to primary care providers | ||||||
25 | who meet that goal. | ||||||
26 | The Department shall devise a means of case-managing or |
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1 | patient navigation for beneficiaries diagnosed with breast | ||||||
2 | cancer. This program shall initially operate as a pilot program | ||||||
3 | in areas of the State with the highest incidence of mortality | ||||||
4 | related to breast cancer. At least one pilot program site shall | ||||||
5 | be in the metropolitan Chicago area and at least one site shall | ||||||
6 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
7 | pilot program shall be carried out measuring health outcomes | ||||||
8 | and cost of care for those served by the pilot program compared | ||||||
9 | to similarly situated patients who are not served by the pilot | ||||||
10 | program. | ||||||
11 | Any medical or health care provider shall immediately | ||||||
12 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
13 | services and is suspected
of drug abuse or is addicted as | ||||||
14 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
15 | Act, referral to a local substance abuse treatment provider
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16 | licensed by the Department of Human Services or to a licensed
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17 | hospital which provides substance abuse treatment services. | ||||||
18 | The Department of Healthcare and Family Services
shall assure | ||||||
19 | coverage for the cost of treatment of the drug abuse or
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20 | addiction for pregnant recipients in accordance with the | ||||||
21 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
22 | Human Services.
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23 | All medical providers providing medical assistance to | ||||||
24 | pregnant women
under this Code shall receive information from | ||||||
25 | the Department on the
availability of services under the Drug | ||||||
26 | Free Families with a Future or any
comparable program providing |
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1 | case management services for addicted women,
including | ||||||
2 | information on appropriate referrals for other social services
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3 | that may be needed by addicted women in addition to treatment | ||||||
4 | for addiction.
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5 | The Illinois Department, in cooperation with the | ||||||
6 | Departments of Human
Services (as successor to the Department | ||||||
7 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
8 | public awareness campaign, may
provide information concerning | ||||||
9 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
10 | health care, and other pertinent programs directed at
reducing | ||||||
11 | the number of drug-affected infants born to recipients of | ||||||
12 | medical
assistance.
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13 | Neither the Department of Healthcare and Family Services | ||||||
14 | nor the Department of Human
Services shall sanction the | ||||||
15 | recipient solely on the basis of
her substance abuse.
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16 | The Illinois Department shall establish such regulations | ||||||
17 | governing
the dispensing of health services under this Article | ||||||
18 | as it shall deem
appropriate. The Department
should
seek the | ||||||
19 | advice of formal professional advisory committees appointed by
| ||||||
20 | the Director of the Illinois Department for the purpose of | ||||||
21 | providing regular
advice on policy and administrative matters, | ||||||
22 | information dissemination and
educational activities for | ||||||
23 | medical and health care providers, and
consistency in | ||||||
24 | procedures to the Illinois Department.
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25 | The Illinois Department may develop and contract with | ||||||
26 | Partnerships of
medical providers to arrange medical services |
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1 | for persons eligible under
Section 5-2 of this Code. | ||||||
2 | Implementation of this Section may be by
demonstration projects | ||||||
3 | in certain geographic areas. The Partnership shall
be | ||||||
4 | represented by a sponsor organization. The Department, by rule, | ||||||
5 | shall
develop qualifications for sponsors of Partnerships. | ||||||
6 | Nothing in this
Section shall be construed to require that the | ||||||
7 | sponsor organization be a
medical organization.
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8 | The sponsor must negotiate formal written contracts with | ||||||
9 | medical
providers for physician services, inpatient and | ||||||
10 | outpatient hospital care,
home health services, treatment for | ||||||
11 | alcoholism and substance abuse, and
other services determined | ||||||
12 | necessary by the Illinois Department by rule for
delivery by | ||||||
13 | Partnerships. Physician services must include prenatal and
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14 | obstetrical care. The Illinois Department shall reimburse | ||||||
15 | medical services
delivered by Partnership providers to clients | ||||||
16 | in target areas according to
provisions of this Article and the | ||||||
17 | Illinois Health Finance Reform Act,
except that:
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18 | (1) Physicians participating in a Partnership and | ||||||
19 | providing certain
services, which shall be determined by | ||||||
20 | the Illinois Department, to persons
in areas covered by the | ||||||
21 | Partnership may receive an additional surcharge
for such | ||||||
22 | services.
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23 | (2) The Department may elect to consider and negotiate | ||||||
24 | financial
incentives to encourage the development of | ||||||
25 | Partnerships and the efficient
delivery of medical care.
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26 | (3) Persons receiving medical services through |
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1 | Partnerships may receive
medical and case management | ||||||
2 | services above the level usually offered
through the | ||||||
3 | medical assistance program.
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4 | Medical providers shall be required to meet certain | ||||||
5 | qualifications to
participate in Partnerships to ensure the | ||||||
6 | delivery of high quality medical
services. These | ||||||
7 | qualifications shall be determined by rule of the Illinois
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8 | Department and may be higher than qualifications for | ||||||
9 | participation in the
medical assistance program. Partnership | ||||||
10 | sponsors may prescribe reasonable
additional qualifications | ||||||
11 | for participation by medical providers, only with
the prior | ||||||
12 | written approval of the Illinois Department.
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13 | Nothing in this Section shall limit the free choice of | ||||||
14 | practitioners,
hospitals, and other providers of medical | ||||||
15 | services by clients.
In order to ensure patient freedom of | ||||||
16 | choice, the Illinois Department shall
immediately promulgate | ||||||
17 | all rules and take all other necessary actions so that
provided | ||||||
18 | services may be accessed from therapeutically certified | ||||||
19 | optometrists
to the full extent of the Illinois Optometric | ||||||
20 | Practice Act of 1987 without
discriminating between service | ||||||
21 | providers.
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22 | The Department shall apply for a waiver from the United | ||||||
23 | States Health
Care Financing Administration to allow for the | ||||||
24 | implementation of
Partnerships under this Section.
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25 | The Illinois Department shall require health care | ||||||
26 | providers to maintain
records that document the medical care |
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1 | and services provided to recipients
of Medical Assistance under | ||||||
2 | this Article. Such records must be retained for a period of not | ||||||
3 | less than 6 years from the date of service or as provided by | ||||||
4 | applicable State law, whichever period is longer, except that | ||||||
5 | if an audit is initiated within the required retention period | ||||||
6 | then the records must be retained until the audit is completed | ||||||
7 | and every exception is resolved. The Illinois Department shall
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8 | require health care providers to make available, when | ||||||
9 | authorized by the
patient, in writing, the medical records in a | ||||||
10 | timely fashion to other
health care providers who are treating | ||||||
11 | or serving persons eligible for
Medical Assistance under this | ||||||
12 | Article. All dispensers of medical services
shall be required | ||||||
13 | to maintain and retain business and professional records
| ||||||
14 | sufficient to fully and accurately document the nature, scope, | ||||||
15 | details and
receipt of the health care provided to persons | ||||||
16 | eligible for medical
assistance under this Code, in accordance | ||||||
17 | with regulations promulgated by
the Illinois Department. The | ||||||
18 | rules and regulations shall require that proof
of the receipt | ||||||
19 | of prescription drugs, dentures, prosthetic devices and
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20 | eyeglasses by eligible persons under this Section accompany | ||||||
21 | each claim
for reimbursement submitted by the dispenser of such | ||||||
22 | medical services.
No such claims for reimbursement shall be | ||||||
23 | approved for payment by the Illinois
Department without such | ||||||
24 | proof of receipt, unless the Illinois Department
shall have put | ||||||
25 | into effect and shall be operating a system of post-payment
| ||||||
26 | audit and review which shall, on a sampling basis, be deemed |
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1 | adequate by
the Illinois Department to assure that such drugs, | ||||||
2 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
3 | is being made are actually being
received by eligible | ||||||
4 | recipients. Within 90 days after the effective date of
this | ||||||
5 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
6 | a
current list of acquisition costs for all prosthetic devices | ||||||
7 | and any
other items recognized as medical equipment and | ||||||
8 | supplies reimbursable under
this Article and shall update such | ||||||
9 | list on a quarterly basis, except that
the acquisition costs of | ||||||
10 | all prescription drugs shall be updated no
less frequently than | ||||||
11 | every 30 days as required by Section 5-5.12.
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12 | The rules and regulations of the Illinois Department shall | ||||||
13 | require
that a written statement including the required opinion | ||||||
14 | of a physician
shall accompany any claim for reimbursement for | ||||||
15 | abortions, or induced
miscarriages or premature births. This | ||||||
16 | statement shall indicate what
procedures were used in providing | ||||||
17 | such medical services.
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18 | Notwithstanding any other law to the contrary, the Illinois | ||||||
19 | Department shall, within 365 days after July 22, 2013 ( the | ||||||
20 | effective date of Public Act 98-104) this amendatory Act of the | ||||||
21 | 98th General Assembly , establish procedures to permit skilled | ||||||
22 | care facilities licensed under the Nursing Home Care Act to | ||||||
23 | submit monthly billing claims for reimbursement purposes. | ||||||
24 | Following development of these procedures, the Department | ||||||
25 | shall have an additional 365 days to test the viability of the | ||||||
26 | new system and to ensure that any necessary operational or |
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1 | structural changes to its information technology platforms are | ||||||
2 | implemented. | ||||||
3 | The Illinois Department shall require all dispensers of | ||||||
4 | medical
services, other than an individual practitioner or | ||||||
5 | group of practitioners,
desiring to participate in the Medical | ||||||
6 | Assistance program
established under this Article to disclose | ||||||
7 | all financial, beneficial,
ownership, equity, surety or other | ||||||
8 | interests in any and all firms,
corporations, partnerships, | ||||||
9 | associations, business enterprises, joint
ventures, agencies, | ||||||
10 | institutions or other legal entities providing any
form of | ||||||
11 | health care services in this State under this Article.
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12 | The Illinois Department may require that all dispensers of | ||||||
13 | medical
services desiring to participate in the medical | ||||||
14 | assistance program
established under this Article disclose, | ||||||
15 | under such terms and conditions as
the Illinois Department may | ||||||
16 | by rule establish, all inquiries from clients
and attorneys | ||||||
17 | regarding medical bills paid by the Illinois Department, which
| ||||||
18 | inquiries could indicate potential existence of claims or liens | ||||||
19 | for the
Illinois Department.
| ||||||
20 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
21 | period and shall be conditional for one year. During the period | ||||||
22 | of conditional enrollment, the Department may
terminate the | ||||||
23 | vendor's eligibility to participate in, or may disenroll the | ||||||
24 | vendor from, the medical assistance
program without cause. | ||||||
25 | Unless otherwise specified, such termination of eligibility or | ||||||
26 | disenrollment is not subject to the
Department's hearing |
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| |||||||
1 | process.
However, a disenrolled vendor may reapply without | ||||||
2 | penalty.
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3 | The Department has the discretion to limit the conditional | ||||||
4 | enrollment period for vendors based upon category of risk of | ||||||
5 | the vendor. | ||||||
6 | Prior to enrollment and during the conditional enrollment | ||||||
7 | period in the medical assistance program, all vendors shall be | ||||||
8 | subject to enhanced oversight, screening, and review based on | ||||||
9 | the risk of fraud, waste, and abuse that is posed by the | ||||||
10 | category of risk of the vendor. The Illinois Department shall | ||||||
11 | establish the procedures for oversight, screening, and review, | ||||||
12 | which may include, but need not be limited to: criminal and | ||||||
13 | financial background checks; fingerprinting; license, | ||||||
14 | certification, and authorization verifications; unscheduled or | ||||||
15 | unannounced site visits; database checks; prepayment audit | ||||||
16 | reviews; audits; payment caps; payment suspensions; and other | ||||||
17 | screening as required by federal or State law. | ||||||
18 | The Department shall define or specify the following: (i) | ||||||
19 | by provider notice, the "category of risk of the vendor" for | ||||||
20 | each type of vendor, which shall take into account the level of | ||||||
21 | screening applicable to a particular category of vendor under | ||||||
22 | federal law and regulations; (ii) by rule or provider notice, | ||||||
23 | the maximum length of the conditional enrollment period for | ||||||
24 | each category of risk of the vendor; and (iii) by rule, the | ||||||
25 | hearing rights, if any, afforded to a vendor in each category | ||||||
26 | of risk of the vendor that is terminated or disenrolled during |
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| |||||||
1 | the conditional enrollment period. | ||||||
2 | To be eligible for payment consideration, a vendor's | ||||||
3 | payment claim or bill, either as an initial claim or as a | ||||||
4 | resubmitted claim following prior rejection, must be received | ||||||
5 | by the Illinois Department, or its fiscal intermediary, no | ||||||
6 | later than 180 days after the latest date on the claim on which | ||||||
7 | medical goods or services were provided, with the following | ||||||
8 | exceptions: | ||||||
9 | (1) In the case of a provider whose enrollment is in | ||||||
10 | process by the Illinois Department, the 180-day period | ||||||
11 | shall not begin until the date on the written notice from | ||||||
12 | the Illinois Department that the provider enrollment is | ||||||
13 | complete. | ||||||
14 | (2) In the case of errors attributable to the Illinois | ||||||
15 | Department or any of its claims processing intermediaries | ||||||
16 | which result in an inability to receive, process, or | ||||||
17 | adjudicate a claim, the 180-day period shall not begin | ||||||
18 | until the provider has been notified of the error. | ||||||
19 | (3) In the case of a provider for whom the Illinois | ||||||
20 | Department initiates the monthly billing process. | ||||||
21 | (4) In the case of a provider operated by a unit of | ||||||
22 | local government with a population exceeding 3,000,000 | ||||||
23 | when local government funds finance federal participation | ||||||
24 | for claims payments. | ||||||
25 | For claims for services rendered during a period for which | ||||||
26 | a recipient received retroactive eligibility, claims must be |
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1 | filed within 180 days after the Department determines the | ||||||
2 | applicant is eligible. For claims for which the Illinois | ||||||
3 | Department is not the primary payer, claims must be submitted | ||||||
4 | to the Illinois Department within 180 days after the final | ||||||
5 | adjudication by the primary payer. | ||||||
6 | In the case of long term care facilities, admission | ||||||
7 | documents shall be submitted within 30 days of an admission to | ||||||
8 | the facility through the Medical Electronic Data Interchange | ||||||
9 | (MEDI) or the Recipient Eligibility Verification (REV) System, | ||||||
10 | or shall be submitted directly to the Department of Human | ||||||
11 | Services using required admission forms. Confirmation numbers | ||||||
12 | assigned to an accepted transaction shall be retained by a | ||||||
13 | facility to verify timely submittal. Once an admission | ||||||
14 | transaction has been completed, all resubmitted claims | ||||||
15 | following prior rejection are subject to receipt no later than | ||||||
16 | 180 days after the admission transaction has been completed. | ||||||
17 | Claims that are not submitted and received in compliance | ||||||
18 | with the foregoing requirements shall not be eligible for | ||||||
19 | payment under the medical assistance program, and the State | ||||||
20 | shall have no liability for payment of those claims. | ||||||
21 | To the extent consistent with applicable information and | ||||||
22 | privacy, security, and disclosure laws, State and federal | ||||||
23 | agencies and departments shall provide the Illinois Department | ||||||
24 | access to confidential and other information and data necessary | ||||||
25 | to perform eligibility and payment verifications and other | ||||||
26 | Illinois Department functions. This includes, but is not |
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1 | limited to: information pertaining to licensure; | ||||||
2 | certification; earnings; immigration status; citizenship; wage | ||||||
3 | reporting; unearned and earned income; pension income; | ||||||
4 | employment; supplemental security income; social security | ||||||
5 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
6 | National Practitioner Data Bank (NPDB); program and agency | ||||||
7 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
8 | corporate information; and death records. | ||||||
9 | The Illinois Department shall enter into agreements with | ||||||
10 | State agencies and departments, and is authorized to enter into | ||||||
11 | agreements with federal agencies and departments, under which | ||||||
12 | such agencies and departments shall share data necessary for | ||||||
13 | medical assistance program integrity functions and oversight. | ||||||
14 | The Illinois Department shall develop, in cooperation with | ||||||
15 | other State departments and agencies, and in compliance with | ||||||
16 | applicable federal laws and regulations, appropriate and | ||||||
17 | effective methods to share such data. At a minimum, and to the | ||||||
18 | extent necessary to provide data sharing, the Illinois | ||||||
19 | Department shall enter into agreements with State agencies and | ||||||
20 | departments, and is authorized to enter into agreements with | ||||||
21 | federal agencies and departments, including but not limited to: | ||||||
22 | the Secretary of State; the Department of Revenue; the | ||||||
23 | Department of Public Health; the Department of Human Services; | ||||||
24 | and the Department of Financial and Professional Regulation. | ||||||
25 | Beginning in fiscal year 2013, the Illinois Department | ||||||
26 | shall set forth a request for information to identify the |
| |||||||
| |||||||
1 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
2 | claims system with the goals of streamlining claims processing | ||||||
3 | and provider reimbursement, reducing the number of pending or | ||||||
4 | rejected claims, and helping to ensure a more transparent | ||||||
5 | adjudication process through the utilization of: (i) provider | ||||||
6 | data verification and provider screening technology; and (ii) | ||||||
7 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
8 | post-adjudicated predictive modeling with an integrated case | ||||||
9 | management system with link analysis. Such a request for | ||||||
10 | information shall not be considered as a request for proposal | ||||||
11 | or as an obligation on the part of the Illinois Department to | ||||||
12 | take any action or acquire any products or services. | ||||||
13 | The Illinois Department shall establish policies, | ||||||
14 | procedures,
standards and criteria by rule for the acquisition, | ||||||
15 | repair and replacement
of orthotic and prosthetic devices and | ||||||
16 | durable medical equipment. Such
rules shall provide, but not be | ||||||
17 | limited to, the following services: (1)
immediate repair or | ||||||
18 | replacement of such devices by recipients; and (2) rental, | ||||||
19 | lease, purchase or lease-purchase of
durable medical equipment | ||||||
20 | in a cost-effective manner, taking into
consideration the | ||||||
21 | recipient's medical prognosis, the extent of the
recipient's | ||||||
22 | needs, and the requirements and costs for maintaining such
| ||||||
23 | equipment. Subject to prior approval, such rules shall enable a | ||||||
24 | recipient to temporarily acquire and
use alternative or | ||||||
25 | substitute devices or equipment pending repairs or
| ||||||
26 | replacements of any device or equipment previously authorized |
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| |||||||
1 | for such
recipient by the Department.
| ||||||
2 | The Department shall execute, relative to the nursing home | ||||||
3 | prescreening
project, written inter-agency agreements with the | ||||||
4 | Department of Human
Services and the Department on Aging, to | ||||||
5 | effect the following: (i) intake
procedures and common | ||||||
6 | eligibility criteria for those persons who are receiving
| ||||||
7 | non-institutional services; and (ii) the establishment and | ||||||
8 | development of
non-institutional services in areas of the State | ||||||
9 | where they are not currently
available or are undeveloped; and | ||||||
10 | (iii) notwithstanding any other provision of law, subject to | ||||||
11 | federal approval, on and after July 1, 2012, an increase in the | ||||||
12 | determination of need (DON) scores from 29 to 37 for applicants | ||||||
13 | for institutional and home and community-based long term care; | ||||||
14 | if and only if federal approval is not granted, the Department | ||||||
15 | may, in conjunction with other affected agencies, implement | ||||||
16 | utilization controls or changes in benefit packages to | ||||||
17 | effectuate a similar savings amount for this population; and | ||||||
18 | (iv) no later than July 1, 2013, minimum level of care | ||||||
19 | eligibility criteria for institutional and home and | ||||||
20 | community-based long term care; and (v) no later than October | ||||||
21 | 1, 2013, establish procedures to permit long term care | ||||||
22 | providers access to eligibility scores for individuals with an | ||||||
23 | admission date who are seeking or receiving services from the | ||||||
24 | long term care provider. In order to select the minimum level | ||||||
25 | of care eligibility criteria, the Governor shall establish a | ||||||
26 | workgroup that includes affected agency representatives and |
| |||||||
| |||||||
1 | stakeholders representing the institutional and home and | ||||||
2 | community-based long term care interests. This Section shall | ||||||
3 | not restrict the Department from implementing lower level of | ||||||
4 | care eligibility criteria for community-based services in | ||||||
5 | circumstances where federal approval has been granted.
| ||||||
6 | The Illinois Department shall develop and operate, in | ||||||
7 | cooperation
with other State Departments and agencies and in | ||||||
8 | compliance with
applicable federal laws and regulations, | ||||||
9 | appropriate and effective
systems of health care evaluation and | ||||||
10 | programs for monitoring of
utilization of health care services | ||||||
11 | and facilities, as it affects
persons eligible for medical | ||||||
12 | assistance under this Code.
| ||||||
13 | The Illinois Department shall report annually to the | ||||||
14 | General Assembly,
no later than the second Friday in April of | ||||||
15 | 1979 and each year
thereafter, in regard to:
| ||||||
16 | (a) actual statistics and trends in utilization of | ||||||
17 | medical services by
public aid recipients;
| ||||||
18 | (b) actual statistics and trends in the provision of | ||||||
19 | the various medical
services by medical vendors;
| ||||||
20 | (c) current rate structures and proposed changes in | ||||||
21 | those rate structures
for the various medical vendors; and
| ||||||
22 | (d) efforts at utilization review and control by the | ||||||
23 | Illinois Department.
| ||||||
24 | The period covered by each report shall be the 3 years | ||||||
25 | ending on the June
30 prior to the report. The report shall | ||||||
26 | include suggested legislation
for consideration by the General |
| |||||||
| |||||||
1 | Assembly. The filing of one copy of the
report with the | ||||||
2 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
3 | the Clerk of the House of Representatives, one copy with the | ||||||
4 | President,
one copy with the Minority Leader and one copy with | ||||||
5 | the Secretary of the
Senate, one copy with the Legislative | ||||||
6 | Research Unit, and such additional
copies
with the State | ||||||
7 | Government Report Distribution Center for the General
Assembly | ||||||
8 | as is required under paragraph (t) of Section 7 of the State
| ||||||
9 | Library Act shall be deemed sufficient to comply with this | ||||||
10 | Section.
| ||||||
11 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
12 | any, is conditioned on the rules being adopted in accordance | ||||||
13 | with all provisions of the Illinois Administrative Procedure | ||||||
14 | Act and all rules and procedures of the Joint Committee on | ||||||
15 | Administrative Rules; any purported rule not so adopted, for | ||||||
16 | whatever reason, is unauthorized. | ||||||
17 | On and after July 1, 2012, the Department shall reduce any | ||||||
18 | rate of reimbursement for services or other payments or alter | ||||||
19 | any methodologies authorized by this Code to reduce any rate of | ||||||
20 | reimbursement for services or other payments in accordance with | ||||||
21 | Section 5-5e. | ||||||
22 | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | ||||||
23 | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | ||||||
24 | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | ||||||
25 | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; revised | ||||||
26 | 9-19-13.)
|
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| |||||||
1 | Section 99. Effective date. This Act takes effect upon | ||||||
2 | becoming law.
|