Bill Text: IL SB2294 | 2021-2022 | 102nd General Assembly | Enrolled
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Creates the Illinois Certified Community Behavioral Health Clinics Act. Requires the Department of Healthcare and Family Services to develop a Comprehensive Statewide Behavioral Health Strategy and to submit this Strategy to the Governor and General Assembly no later than July 1, 2022. Provides that the Strategy shall address key components of current and past legislation as well as current initiatives related to behavioral health services in order to develop a cohesive behavioral health system. Requires the Department to establish, by January 1, 2022, a program for the implementation of certified community behavioral health clinics. Amends the Medical Assistance Article of the Illinois Public Aid Code. Contains provisions concerning inpatient hospitalization for opioid-related overdose or withdrawal patients; services provided by licensed clinical professional counselors and marriage and family therapists; payments for long-acting injectable medications for mental health or substance use disorders; medical assistance benefits for persons determined eligible during the COVID-19 public health emergency; medical assistance coverage for services performed by a chiropractic physician, including, but not limited to, chiropractic manipulative treatment; medical assistance coverage for federally approved tobacco cessation medications and for tobacco cessation counseling services and medications provided through the Illinois Tobacco Quitline; medical assistance coverage for noncitizens for immunosuppressive drugs and related services associated with post-kidney transplant management, excluding long-term care costs; hospital reimbursements for immunizations; supplemental per diem rates for supportive living facilities; a supports waiver program for young adults with developmental disabilities; prior approval for wheelchair repairs; increased funding for dental services; and other matters. Removes a provision that requires the Department of Healthcare and Family Services to post the contracted claims report required by HealthChoice Illinois on its website every 3 months. In a provision requiring vendor payment claims to be received by the Department of Healthcare and Family Services within a specified time period, provides an exception to the filing deadline in cases established by Department rule. Provides that subject to federal approval, children younger than 19 with income at or below 313% of the federal poverty level shall be eligible for medical assistance. Grants the Department of Healthcare and Family Services emergency rulemaking authority. Provides that those provisions under the Illinois Public Aid Code that grant the Department of Healthcare and Family Services the authority to recover the value of health care benefits provided to a recipient under the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act shall remain in force as to those causes of actions that accrued prior to the date upon which the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act become inoperative. Permits the Department to forgive, compromise, or reduce any debt owed by a former or current recipient of medical assistance under the Illinois Public Aid Code or health care benefits under the Children's Health Insurance Program or the Covering ALL KIDS Health Insurance Program. Amends the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act. Makes the Acts inoperative if (i) the Department of Healthcare and Family Services receives federal approval to make children younger than 19 who have countable income at or below 313% of the federal poverty level eligible for medical assistance under the Illinois Public Aid Code and (ii) the Department, upon federal approval, transitions children eligible for health care benefits under the Acts into the medical assistance program. Amends the Department of Healthcare and Family Services Law. Requires the Department of Healthcare and Family Services to recognize veteran support specialists who are certified by, and in good standing with, the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc. as mental health professionals as defined in the Illinois Title XIX State Plan and in the Illinois Administrative Code. Amends the All-Inclusive Care for the Elderly Act. Changes the name of the Act to the "Program of All-Inclusive Care for the Elderly Act". Requires the Department of Healthcare and Family Services to prepare and submit a PACE State Plan amendment no later than December 31, 2022 to the federal Centers for Medicare and Medicaid Services to establish the Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services under the Illinois Title XIX State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the Department of Healthcare and Family Services, and PACE organizations. Amends the Illinois Health Information Exchange and Technology Act. Changes the repeal date for the Act to January 1, 2027 (rather than January 1, 2022). Amends the Children with Disabilities Article of the School Code. Provides that the Community and Residential Services Authority shall have the power and duty to establish a pilot program to act as a residential research hub to research and identify appropriate residential settings for youth who are being housed in an emergency room for more than 72 hours or who are deemed beyond medical necessity in a psychiatric hospital. Provides that if a child is deemed beyond medical necessity in a psychiatric hospital and is in need of residential placement, the goal of the program is to prevent a lock-out pursuant to the goals of the Custody Relinquishment Prevention Act. Provides that the Executive Director of the Authority or his or her designee shall be added as a participant on the Interagency Clinical Team established in the intergovernmental agreement among the Department of Healthcare and Family Services, the Department of Children and Family Services, the Department of Human Services, the State Board of Education, the Department of Juvenile Justice, and the Department of Public Health, with consent of the youth or the youth's guardian or family pursuant to the Custody Relinquishment Prevention Act. Effective immediately.
Spectrum: Partisan Bill (Democrat 7-0)
Status: (Passed) 2021-07-06 - Public Act . . . . . . . . . 102-0043 [SB2294 Detail]
Download: Illinois-2021-SB2294-Enrolled.html
Bill Title: Creates the Illinois Certified Community Behavioral Health Clinics Act. Requires the Department of Healthcare and Family Services to develop a Comprehensive Statewide Behavioral Health Strategy and to submit this Strategy to the Governor and General Assembly no later than July 1, 2022. Provides that the Strategy shall address key components of current and past legislation as well as current initiatives related to behavioral health services in order to develop a cohesive behavioral health system. Requires the Department to establish, by January 1, 2022, a program for the implementation of certified community behavioral health clinics. Amends the Medical Assistance Article of the Illinois Public Aid Code. Contains provisions concerning inpatient hospitalization for opioid-related overdose or withdrawal patients; services provided by licensed clinical professional counselors and marriage and family therapists; payments for long-acting injectable medications for mental health or substance use disorders; medical assistance benefits for persons determined eligible during the COVID-19 public health emergency; medical assistance coverage for services performed by a chiropractic physician, including, but not limited to, chiropractic manipulative treatment; medical assistance coverage for federally approved tobacco cessation medications and for tobacco cessation counseling services and medications provided through the Illinois Tobacco Quitline; medical assistance coverage for noncitizens for immunosuppressive drugs and related services associated with post-kidney transplant management, excluding long-term care costs; hospital reimbursements for immunizations; supplemental per diem rates for supportive living facilities; a supports waiver program for young adults with developmental disabilities; prior approval for wheelchair repairs; increased funding for dental services; and other matters. Removes a provision that requires the Department of Healthcare and Family Services to post the contracted claims report required by HealthChoice Illinois on its website every 3 months. In a provision requiring vendor payment claims to be received by the Department of Healthcare and Family Services within a specified time period, provides an exception to the filing deadline in cases established by Department rule. Provides that subject to federal approval, children younger than 19 with income at or below 313% of the federal poverty level shall be eligible for medical assistance. Grants the Department of Healthcare and Family Services emergency rulemaking authority. Provides that those provisions under the Illinois Public Aid Code that grant the Department of Healthcare and Family Services the authority to recover the value of health care benefits provided to a recipient under the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act shall remain in force as to those causes of actions that accrued prior to the date upon which the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act become inoperative. Permits the Department to forgive, compromise, or reduce any debt owed by a former or current recipient of medical assistance under the Illinois Public Aid Code or health care benefits under the Children's Health Insurance Program or the Covering ALL KIDS Health Insurance Program. Amends the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act. Makes the Acts inoperative if (i) the Department of Healthcare and Family Services receives federal approval to make children younger than 19 who have countable income at or below 313% of the federal poverty level eligible for medical assistance under the Illinois Public Aid Code and (ii) the Department, upon federal approval, transitions children eligible for health care benefits under the Acts into the medical assistance program. Amends the Department of Healthcare and Family Services Law. Requires the Department of Healthcare and Family Services to recognize veteran support specialists who are certified by, and in good standing with, the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc. as mental health professionals as defined in the Illinois Title XIX State Plan and in the Illinois Administrative Code. Amends the All-Inclusive Care for the Elderly Act. Changes the name of the Act to the "Program of All-Inclusive Care for the Elderly Act". Requires the Department of Healthcare and Family Services to prepare and submit a PACE State Plan amendment no later than December 31, 2022 to the federal Centers for Medicare and Medicaid Services to establish the Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services under the Illinois Title XIX State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the Department of Healthcare and Family Services, and PACE organizations. Amends the Illinois Health Information Exchange and Technology Act. Changes the repeal date for the Act to January 1, 2027 (rather than January 1, 2022). Amends the Children with Disabilities Article of the School Code. Provides that the Community and Residential Services Authority shall have the power and duty to establish a pilot program to act as a residential research hub to research and identify appropriate residential settings for youth who are being housed in an emergency room for more than 72 hours or who are deemed beyond medical necessity in a psychiatric hospital. Provides that if a child is deemed beyond medical necessity in a psychiatric hospital and is in need of residential placement, the goal of the program is to prevent a lock-out pursuant to the goals of the Custody Relinquishment Prevention Act. Provides that the Executive Director of the Authority or his or her designee shall be added as a participant on the Interagency Clinical Team established in the intergovernmental agreement among the Department of Healthcare and Family Services, the Department of Children and Family Services, the Department of Human Services, the State Board of Education, the Department of Juvenile Justice, and the Department of Public Health, with consent of the youth or the youth's guardian or family pursuant to the Custody Relinquishment Prevention Act. Effective immediately.
Spectrum: Partisan Bill (Democrat 7-0)
Status: (Passed) 2021-07-06 - Public Act . . . . . . . . . 102-0043 [SB2294 Detail]
Download: Illinois-2021-SB2294-Enrolled.html
| |||||||
| |||||||
| |||||||
1 | AN ACT concerning regulation.
| ||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||
3 | represented in the General Assembly:
| ||||||
4 | Article 3. | ||||||
5 | Section 3-1. Short title. This Act may be cited as the | ||||||
6 | Illinois Certified Community Behavioral Health Clinics Act.
| ||||||
7 | Section 3-5. Certified Community Behavioral Health Clinic | ||||||
8 | program. The Department of Healthcare and Family Services, in | ||||||
9 | collaboration with the Department of Human Services and with | ||||||
10 | meaningful input from customers and key behavioral health | ||||||
11 | stakeholders, shall develop a Comprehensive Statewide | ||||||
12 | Behavioral Health Strategy and shall submit this Strategy to | ||||||
13 | the Governor and General Assembly no later than July 1, 2022. | ||||||
14 | The Strategy shall address key components of current and past | ||||||
15 | legislation as well as current initiatives related to | ||||||
16 | behavioral health services in order to develop a cohesive | ||||||
17 | behavioral health system that reduces the administrative
| ||||||
18 | burden for customers and providers and includes: (i) | ||||||
19 | comprehensive home and community-based services; (ii) | ||||||
20 | integrated mental health, substance use disorder, and physical | ||||||
21 | health services, and social determinants of health; and (iii) | ||||||
22 | innovative payment models that support providers in offering |
| |||||||
| |||||||
1 | integrated services that are clinically effective and fiscally | ||||||
2 | supported. The Strategy shall consolidate required pilots and | ||||||
3 | initiatives into a cohesive behavioral health system designed | ||||||
4 | to serve both adults and children in the least restrictive | ||||||
5 | setting, as early as possible, once behavioral health needs | ||||||
6 | have been identified, and through evidence-informed practices | ||||||
7 | identified by the Substance Abuse and Mental Health Services | ||||||
8 | Administration (SAMHSA) and other national experts. The | ||||||
9 | Strategy shall take into consideration initiatives such as the | ||||||
10 | Healthcare Transformation Collaboratives program; integrated | ||||||
11 | health homes; services offered under federal Medicaid waiver | ||||||
12 | authorities, including Sections 1915(i) and 1115 of the Social | ||||||
13 | Security Act; requirements for certified community behavioral | ||||||
14 | health centers; enhanced team-based services; housing and | ||||||
15 | employment supports; and other initiatives identified by | ||||||
16 | customers and stakeholders. The Strategy shall also identify | ||||||
17 | the proper capacity for residential and institutional services | ||||||
18 | while emphasizing serving customers in the community. | ||||||
19 | As part of the Strategy development process, by January 1, | ||||||
20 | 2022 the Department of Healthcare and Family Services shall | ||||||
21 | establish a program for the implementation of certified | ||||||
22 | community behavioral health clinics. Behavioral health | ||||||
23 | services providers that received federal grant funding from | ||||||
24 | SAMHSA for the implementation of certified community | ||||||
25 | behavioral health clinics prior to July 1, 2021 shall be | ||||||
26 | eligible to participate in the program established in |
| |||||||
| |||||||
1 | accordance with this Section.
| ||||||
2 | Article 5. | ||||||
3 | Section 5-5. The Illinois Public Aid Code is amended by | ||||||
4 | changing Section 5-5f and by adding Section 5-41 as follows:
| ||||||
5 | (305 ILCS 5/5-5f)
| ||||||
6 | Sec. 5-5f. Elimination and limitations of medical | ||||||
7 | assistance services. Notwithstanding any other provision of | ||||||
8 | this Code to the contrary, on and after July 1, 2012: | ||||||
9 | (a) The following services shall no longer be a | ||||||
10 | covered service available under this Code: group | ||||||
11 | psychotherapy for residents of any facility licensed under | ||||||
12 | the Nursing Home Care Act or the Specialized Mental Health | ||||||
13 | Rehabilitation Act of 2013; and adult chiropractic | ||||||
14 | services. | ||||||
15 | (b) The Department shall place the following | ||||||
16 | limitations on services: (i) the Department shall limit | ||||||
17 | adult eyeglasses to one pair every 2 years; however, the | ||||||
18 | limitation does not apply to an individual who needs | ||||||
19 | different eyeglasses following a surgical procedure such | ||||||
20 | as cataract surgery; (ii) the Department shall set an | ||||||
21 | annual limit of a maximum of 20 visits for each of the | ||||||
22 | following services: adult speech, hearing, and language | ||||||
23 | therapy services, adult occupational therapy services, and |
| |||||||
| |||||||
1 | physical therapy services; on or after October 1, 2014, | ||||||
2 | the annual maximum limit of 20 visits shall expire but the | ||||||
3 | Department may require prior approval for all individuals | ||||||
4 | for speech, hearing, and language therapy services, | ||||||
5 | occupational therapy services, and physical therapy | ||||||
6 | services; (iii) the Department shall limit adult podiatry | ||||||
7 | services to individuals with diabetes; on or after October | ||||||
8 | 1, 2014, podiatry services shall not be limited to | ||||||
9 | individuals with diabetes; (iv) the Department shall pay | ||||||
10 | for caesarean sections at the normal vaginal delivery rate | ||||||
11 | unless a caesarean section was medically necessary; (v) | ||||||
12 | the Department shall limit adult dental services to | ||||||
13 | emergencies; beginning July 1, 2013, the Department shall | ||||||
14 | ensure that the following conditions are recognized as | ||||||
15 | emergencies: (A) dental services necessary for an | ||||||
16 | individual in order for the individual to be cleared for a | ||||||
17 | medical procedure, such as a transplant;
(B) extractions | ||||||
18 | and dentures necessary for a diabetic to receive proper | ||||||
19 | nutrition;
(C) extractions and dentures necessary as a | ||||||
20 | result of cancer treatment; and (D) dental services | ||||||
21 | necessary for the health of a pregnant woman prior to | ||||||
22 | delivery of her baby; on or after July 1, 2014, adult | ||||||
23 | dental services shall no longer be limited to emergencies, | ||||||
24 | and dental services necessary for the health of a pregnant | ||||||
25 | woman prior to delivery of her baby shall continue to be | ||||||
26 | covered; and (vi) effective July 1, 2012 through June 30, |
| |||||||
| |||||||
1 | 2021 , the Department shall place limitations and require | ||||||
2 | concurrent review on every inpatient detoxification stay | ||||||
3 | to prevent repeat admissions to any hospital for | ||||||
4 | detoxification within 60 days of a previous inpatient | ||||||
5 | detoxification stay. The Department shall convene a | ||||||
6 | workgroup of hospitals, substance abuse providers, care | ||||||
7 | coordination entities, managed care plans, and other | ||||||
8 | stakeholders to develop recommendations for quality | ||||||
9 | standards, diversion to other settings, and admission | ||||||
10 | criteria for patients who need inpatient detoxification, | ||||||
11 | which shall be published on the Department's website no | ||||||
12 | later than September 1, 2013. | ||||||
13 | (c) The Department shall require prior approval of the | ||||||
14 | following services: wheelchair repairs costing more than | ||||||
15 | $400, coronary artery bypass graft, and bariatric surgery | ||||||
16 | consistent with Medicare standards concerning patient | ||||||
17 | responsibility. Wheelchair repair prior approval requests | ||||||
18 | shall be adjudicated within one business day of receipt of | ||||||
19 | complete supporting documentation. Providers may not break | ||||||
20 | wheelchair repairs into separate claims for purposes of | ||||||
21 | staying under the $400 threshold for requiring prior | ||||||
22 | approval. The wholesale price of manual and power | ||||||
23 | wheelchairs, durable medical equipment and supplies, and | ||||||
24 | complex rehabilitation technology products and services | ||||||
25 | shall be defined as actual acquisition cost including all | ||||||
26 | discounts. |
| |||||||
| |||||||
1 | (d) The Department shall establish benchmarks for | ||||||
2 | hospitals to measure and align payments to reduce | ||||||
3 | potentially preventable hospital readmissions, inpatient | ||||||
4 | complications, and unnecessary emergency room visits. In | ||||||
5 | doing so, the Department shall consider items, including, | ||||||
6 | but not limited to, historic and current acuity of care | ||||||
7 | and historic and current trends in readmission. The | ||||||
8 | Department shall publish provider-specific historical | ||||||
9 | readmission data and anticipated potentially preventable | ||||||
10 | targets 60 days prior to the start of the program. In the | ||||||
11 | instance of readmissions, the Department shall adopt | ||||||
12 | policies and rates of reimbursement for services and other | ||||||
13 | payments provided under this Code to ensure that, by June | ||||||
14 | 30, 2013, expenditures to hospitals are reduced by, at a | ||||||
15 | minimum, $40,000,000. | ||||||
16 | (e) The Department shall establish utilization | ||||||
17 | controls for the hospice program such that it shall not | ||||||
18 | pay for other care services when an individual is in | ||||||
19 | hospice. | ||||||
20 | (f) For home health services, the Department shall | ||||||
21 | require Medicare certification of providers participating | ||||||
22 | in the program and implement the Medicare face-to-face | ||||||
23 | encounter rule. The Department shall require providers to | ||||||
24 | implement auditable electronic service verification based | ||||||
25 | on global positioning systems or other cost-effective | ||||||
26 | technology. |
| |||||||
| |||||||
1 | (g) For the Home Services Program operated by the | ||||||
2 | Department of Human Services and the Community Care | ||||||
3 | Program operated by the Department on Aging, the | ||||||
4 | Department of Human Services, in cooperation with the | ||||||
5 | Department on Aging, shall implement an electronic service | ||||||
6 | verification based on global positioning systems or other | ||||||
7 | cost-effective technology. | ||||||
8 | (h) Effective with inpatient hospital admissions on or | ||||||
9 | after July 1, 2012, the Department shall reduce the | ||||||
10 | payment for a claim that indicates the occurrence of a | ||||||
11 | provider-preventable condition during the admission as | ||||||
12 | specified by the Department in rules. The Department shall | ||||||
13 | not pay for services related to an other | ||||||
14 | provider-preventable condition. | ||||||
15 | As used in this subsection (h): | ||||||
16 | "Provider-preventable condition" means a health care | ||||||
17 | acquired condition as defined under the federal Medicaid | ||||||
18 | regulation found at 42 CFR 447.26 or an other | ||||||
19 | provider-preventable condition. | ||||||
20 | "Other provider-preventable condition" means a wrong | ||||||
21 | surgical or other invasive procedure performed on a | ||||||
22 | patient, a surgical or other invasive procedure performed | ||||||
23 | on the wrong body part, or a surgical procedure or other | ||||||
24 | invasive procedure performed on the wrong patient. | ||||||
25 | (i) The Department shall implement cost savings | ||||||
26 | initiatives for advanced imaging services, cardiac imaging |
| |||||||
| |||||||
1 | services, pain management services, and back surgery. Such | ||||||
2 | initiatives shall be designed to achieve annual costs | ||||||
3 | savings.
| ||||||
4 | (j) The Department shall ensure that beneficiaries | ||||||
5 | with a diagnosis of epilepsy or seizure disorder in | ||||||
6 | Department records will not require prior approval for | ||||||
7 | anticonvulsants. | ||||||
8 | (Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
| ||||||
9 | (305 ILCS 5/5-41 new) | ||||||
10 | Sec. 5-41. Inpatient hospitalization for opioid-related | ||||||
11 | overdose or withdrawal patients. Due to the disproportionately | ||||||
12 | high opioid-related fatality rates among African Americans in | ||||||
13 | under-resourced communities in Illinois, the lack of community | ||||||
14 | resources, the comorbidities experienced by these patients, | ||||||
15 | and the high rate of hospital inpatient recidivism associated | ||||||
16 | with this population when improperly treated, the Department | ||||||
17 | shall ensure that patients, whether enrolled under the Medical | ||||||
18 | Assistance Fee For Service program or enrolled with a Medicaid | ||||||
19 | Managed Care Organization, experiencing opioid-related | ||||||
20 | overdose or withdrawal are admitted on an inpatient status and | ||||||
21 | the provider shall be reimbursed accordingly, when deemed | ||||||
22 | medically necessary, as determined by either the patient's | ||||||
23 | primary care physician, or the physician or other practitioner | ||||||
24 | responsible for the patient's care at the hospital to which | ||||||
25 | the patient presents, using criteria established by the |
| |||||||
| |||||||
1 | American Society of Addiction Medicine. If it is determined by | ||||||
2 | the physician or other practitioner responsible for the | ||||||
3 | patient's care at the hospital to which the patient presents, | ||||||
4 | that a patient does not meet medical necessity criteria for | ||||||
5 | the admission, then the patient may be treated via observation | ||||||
6 | and the provider shall seek reimbursement accordingly. Nothing | ||||||
7 | in this Section shall diminish the requirements of a provider | ||||||
8 | to document medical necessity in the patient's record.
| ||||||
9 | Article 10. | ||||||
10 | Section 10-5. The Illinois Public Aid Code is amended by | ||||||
11 | changing Section 5-8 as follows:
| ||||||
12 | (305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
| ||||||
13 | Sec. 5-8. Practitioners. In supplying medical assistance, | ||||||
14 | the Illinois
Department may provide for the legally authorized | ||||||
15 | services of (i) persons
licensed under the Medical Practice | ||||||
16 | Act of 1987, as amended, except as
hereafter in this Section | ||||||
17 | stated, whether under a
general or limited license, (ii) | ||||||
18 | persons licensed under the Nurse Practice Act as advanced | ||||||
19 | practice registered nurses, regardless of whether or not the | ||||||
20 | persons have written collaborative agreements, (iii) persons | ||||||
21 | licensed or registered
under
other laws of this State to | ||||||
22 | provide dental, medical, pharmaceutical,
optometric, | ||||||
23 | podiatric, or nursing services, or other remedial care
|
| |||||||
| |||||||
1 | recognized under State law, (iv) persons licensed under other | ||||||
2 | laws of
this State as a clinical social worker, and (v) persons | ||||||
3 | licensed under other laws of this State as physician | ||||||
4 | assistants. The Department shall adopt rules, no later than 90 | ||||||
5 | days after January 1, 2017 (the effective date of Public Act | ||||||
6 | 99-621), for the legally authorized services of persons | ||||||
7 | licensed under other laws of this State as a clinical social | ||||||
8 | worker.
The Department shall provide for the legally | ||||||
9 | authorized services of persons licensed under the Professional | ||||||
10 | Counselor and Clinical Professional Counselor Licensing and | ||||||
11 | Practice Act as clinical professional counselors and for the | ||||||
12 | legally
authorized services of persons licensed under the | ||||||
13 | Marriage and
Family Therapy Licensing Act as marriage and | ||||||
14 | family
therapists. The
utilization of the services of persons | ||||||
15 | engaged in the treatment or care of
the sick, which persons are | ||||||
16 | not required to be licensed or registered under
the laws of | ||||||
17 | this State, is not prohibited by this Section.
| ||||||
18 | (Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17; | ||||||
19 | 100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff. | ||||||
20 | 1-1-18; 100-863, eff. 8-14-18.)
| ||||||
21 | Article 15. | ||||||
22 | Section 15-5. The Department of Healthcare and Family | ||||||
23 | Services Law of the
Civil Administrative Code of Illinois is | ||||||
24 | amended by adding Section 2205-35 as follows:
|
| |||||||
| |||||||
1 | (20 ILCS 2205/2205-35 new) | ||||||
2 | Sec. 2205-35. Certified veteran support specialists. The | ||||||
3 | Department of Healthcare and Family Services shall recognize | ||||||
4 | veteran support specialists who are certified by, and in good | ||||||
5 | standing with, the Illinois Alcohol and Other Drug Abuse | ||||||
6 | Professional Certification Association, Inc. as mental health | ||||||
7 | professionals as defined in the Illinois Title XIX State Plan | ||||||
8 | and in 89 Ill. Adm. Code 140.453.
| ||||||
9 | Article 20. | ||||||
10 | Section 20-5. The Illinois Public Aid Code is amended by | ||||||
11 | adding Section 5-5.4k as follows:
| ||||||
12 | (305 ILCS 5/5-5.4k new) | ||||||
13 | Sec. 5-5.4k. Payments for long-acting injectable | ||||||
14 | medications for mental health or substance use disorders. | ||||||
15 | Notwithstanding any other provision of this Code, effective | ||||||
16 | for dates of service on and after January 1, 2022, the medical | ||||||
17 | assistance program shall separately reimburse at the | ||||||
18 | prevailing fee schedule, for long-acting injectable | ||||||
19 | medications administered for mental health or substance use | ||||||
20 | disorder in the hospital inpatient setting, and which are | ||||||
21 | compliant with the prior authorization requirements of this | ||||||
22 | Section. The Department, in consultation with a statewide |
| |||||||
| |||||||
1 | association representing a majority of hospitals and Managed | ||||||
2 | Care Organizations shall implement, by rule, reimbursement | ||||||
3 | policy and prior authorization criteria for the use of | ||||||
4 | long-acting injectable medications administered in the | ||||||
5 | hospital inpatient setting for the treatment of mental health | ||||||
6 | disorders.
| ||||||
7 | Article 25. | ||||||
8 | Section 25-3. The Illinois Administrative Procedure Act is | ||||||
9 | amended by adding Section 5-45.8 as follows:
| ||||||
10 | (5 ILCS 100/5-45.8 new) | ||||||
11 | Sec. 5-45.8. Emergency rulemaking; Medicaid eligibility | ||||||
12 | expansion. To provide for the expeditious and timely | ||||||
13 | implementation of the changes made to paragraph 6 of Section | ||||||
14 | 5-2 of the Illinois Public Aid Code by this amendatory Act of | ||||||
15 | the 102nd General Assembly, emergency rules implementing the | ||||||
16 | changes made to paragraph 6 of Section 5-2 of the Illinois | ||||||
17 | Public Aid Code by this amendatory Act of the 102nd General | ||||||
18 | Assembly may be adopted in accordance with Section 5-45 by the | ||||||
19 | Department of Healthcare and Family Services. The adoption of | ||||||
20 | emergency rules authorized by Section 5-45 and this Section is | ||||||
21 | deemed to be necessary for the public interest, safety, and | ||||||
22 | welfare. | ||||||
23 | This Section is repealed on January 1, 2027.
|
| |||||||
| |||||||
1 | Section 25-5. The Children's Health Insurance Program Act | ||||||
2 | is amended by adding Section 6 as follows:
| ||||||
3 | (215 ILCS 106/6 new) | ||||||
4 | Sec. 6. Act inoperative. This Act is inoperative if (i) | ||||||
5 | the Department of Healthcare and Family Services receives | ||||||
6 | federal approval to make children younger than 19 who have | ||||||
7 | countable income at or below 313% of the federal poverty level | ||||||
8 | eligible for medical assistance under Article V of the | ||||||
9 | Illinois Public Aid Code and (ii) the Department, upon federal | ||||||
10 | approval, transitions children eligible for health care | ||||||
11 | benefits under this Act into the medical assistance program | ||||||
12 | established under Article V of the Illinois Public Aid Code.
| ||||||
13 | Section 25-10. The Covering ALL KIDS Health Insurance Act | ||||||
14 | is amended by adding Section 6 as follows:
| ||||||
15 | (215 ILCS 170/6 new) | ||||||
16 | Sec. 6. Act inoperative. This Act is inoperative if (i) | ||||||
17 | the Department of Healthcare and Family Services receives | ||||||
18 | federal approval to make children younger than 19 who have | ||||||
19 | countable income at or below 313% of the federal poverty level | ||||||
20 | eligible for medical assistance under Article V of the | ||||||
21 | Illinois Public Aid Code and (ii) the Department, upon federal | ||||||
22 | approval, transitions children eligible for health care |
| |||||||
| |||||||
1 | benefits under this Act into the medical assistance program | ||||||
2 | established under Article V of the Illinois Public Aid Code.
| ||||||
3 | Section 25-15. The Illinois Public Aid Code is amended by | ||||||
4 | changing Sections 5-1.5, 5-2, and 12-4.35, and by adding | ||||||
5 | Sections 11-4.2, 11-22d, and 11-32 as follows:
| ||||||
6 | (305 ILCS 5/5-1.5) | ||||||
7 | Sec. 5-1.5. COVID-19 public health emergency. | ||||||
8 | Notwithstanding any other provision of Articles V, XI, and XII | ||||||
9 | of this Code, the Department may take necessary actions to | ||||||
10 | address the COVID-19 public health emergency to the extent | ||||||
11 | such actions are required, approved, or authorized by the | ||||||
12 | United States Department of Health and Human Services, Centers | ||||||
13 | for Medicare and Medicaid Services. Such actions may continue | ||||||
14 | throughout the public health emergency and for up to 12 months | ||||||
15 | after the period ends, and may include, but are not limited to: | ||||||
16 | accepting an applicant's or recipient's attestation of income, | ||||||
17 | incurred medical expenses, residency, and insured status when | ||||||
18 | electronic verification is not available; eliminating resource | ||||||
19 | tests for some eligibility determinations; suspending | ||||||
20 | redeterminations; suspending changes that would adversely | ||||||
21 | affect an applicant's or recipient's eligibility; phone or | ||||||
22 | verbal approval by an applicant to submit an application in | ||||||
23 | lieu of applicant signature; allowing adult presumptive | ||||||
24 | eligibility; allowing presumptive eligibility for children, |
| |||||||
| |||||||
1 | pregnant women, and adults as often as twice per calendar | ||||||
2 | year; paying for additional services delivered by telehealth; | ||||||
3 | and suspending premium and co-payment requirements. | ||||||
4 | The Department's authority under this Section shall only | ||||||
5 | extend to encompass, incorporate, or effectuate the terms, | ||||||
6 | items, conditions, and other provisions approved, authorized, | ||||||
7 | or required by the United States Department of Health and | ||||||
8 | Human Services, Centers for Medicare and Medicaid Services, | ||||||
9 | and shall not extend beyond the time of the COVID-19 public | ||||||
10 | health emergency and up to 12 months after the period expires.
| ||||||
11 | Any individual determined eligible for medical assistance | ||||||
12 | under this Code as of or during the COVID-19 public health | ||||||
13 | emergency may be treated as eligible for such medical | ||||||
14 | assistance benefits during the COVID-19 public health | ||||||
15 | emergency, and up to 12 months after the period expires, | ||||||
16 | regardless of whether federally required or whether the | ||||||
17 | individual's eligibility may be State or federally funded, | ||||||
18 | unless the individual requests a voluntary termination of | ||||||
19 | eligibility or ceases to be a resident. This paragraph shall | ||||||
20 | not restrict any determination of medical need or | ||||||
21 | appropriateness for any particular service and shall not | ||||||
22 | require continued coverage of any particular service that may | ||||||
23 | be no longer necessary, appropriate, or otherwise authorized | ||||||
24 | for an individual. Nothing shall prevent the Department from | ||||||
25 | determining and properly establishing an individual's | ||||||
26 | eligibility under a different category of eligibility. |
| |||||||
| |||||||
1 | (Source: P.A. 101-649, eff. 7-7-20.)
| ||||||
2 | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| ||||||
3 | Sec. 5-2. Classes of persons eligible. Medical assistance | ||||||
4 | under this
Article shall be available to any of the following | ||||||
5 | classes of persons in
respect to whom a plan for coverage has | ||||||
6 | been submitted to the Governor
by the Illinois Department and | ||||||
7 | approved by him. If changes made in this Section 5-2 require | ||||||
8 | federal approval, they shall not take effect until such | ||||||
9 | approval has been received:
| ||||||
10 | 1. Recipients of basic maintenance grants under | ||||||
11 | Articles III and IV.
| ||||||
12 | 2. Beginning January 1, 2014, persons otherwise | ||||||
13 | eligible for basic maintenance under Article
III, | ||||||
14 | excluding any eligibility requirements that are | ||||||
15 | inconsistent with any federal law or federal regulation, | ||||||
16 | as interpreted by the U.S. Department of Health and Human | ||||||
17 | Services, but who fail to qualify thereunder on the basis | ||||||
18 | of need, and
who have insufficient income and resources to | ||||||
19 | meet the costs of
necessary medical care, including , but | ||||||
20 | not limited to , the following:
| ||||||
21 | (a) All persons otherwise eligible for basic | ||||||
22 | maintenance under Article
III but who fail to qualify | ||||||
23 | under that Article on the basis of need and who
meet | ||||||
24 | either of the following requirements:
| ||||||
25 | (i) their income, as determined by the |
| |||||||
| |||||||
1 | Illinois Department in
accordance with any federal | ||||||
2 | requirements, is equal to or less than 100% of the | ||||||
3 | federal poverty level; or
| ||||||
4 | (ii) their income, after the deduction of | ||||||
5 | costs incurred for medical
care and for other | ||||||
6 | types of remedial care, is equal to or less than | ||||||
7 | 100% of the federal poverty level.
| ||||||
8 | (b) (Blank).
| ||||||
9 | 3. (Blank).
| ||||||
10 | 4. Persons not eligible under any of the preceding | ||||||
11 | paragraphs who fall
sick, are injured, or die, not having | ||||||
12 | sufficient money, property or other
resources to meet the | ||||||
13 | costs of necessary medical care or funeral and burial
| ||||||
14 | expenses.
| ||||||
15 | 5.(a) Beginning January 1, 2020, women during | ||||||
16 | pregnancy and during the
12-month period beginning on the | ||||||
17 | last day of the pregnancy, together with
their infants,
| ||||||
18 | whose income is at or below 200% of the federal poverty | ||||||
19 | level. Until September 30, 2019, or sooner if the | ||||||
20 | maintenance of effort requirements under the Patient | ||||||
21 | Protection and Affordable Care Act are eliminated or may | ||||||
22 | be waived before then, women during pregnancy and during | ||||||
23 | the 12-month period beginning on the last day of the | ||||||
24 | pregnancy, whose countable monthly income, after the | ||||||
25 | deduction of costs incurred for medical care and for other | ||||||
26 | types of remedial care as specified in administrative |
| |||||||
| |||||||
1 | rule, is equal to or less than the Medical Assistance-No | ||||||
2 | Grant(C) (MANG(C)) Income Standard in effect on April 1, | ||||||
3 | 2013 as set forth in administrative rule.
| ||||||
4 | (b) The plan for coverage shall provide ambulatory | ||||||
5 | prenatal care to pregnant women during a
presumptive | ||||||
6 | eligibility period and establish an income eligibility | ||||||
7 | standard
that is equal to 200% of the federal poverty | ||||||
8 | level, provided that costs incurred
for medical care are | ||||||
9 | not taken into account in determining such income
| ||||||
10 | eligibility.
| ||||||
11 | (c) The Illinois Department may conduct a | ||||||
12 | demonstration in at least one
county that will provide | ||||||
13 | medical assistance to pregnant women, together
with their | ||||||
14 | infants and children up to one year of age,
where the | ||||||
15 | income
eligibility standard is set up to 185% of the | ||||||
16 | nonfarm income official
poverty line, as defined by the | ||||||
17 | federal Office of Management and Budget.
The Illinois | ||||||
18 | Department shall seek and obtain necessary authorization
| ||||||
19 | provided under federal law to implement such a | ||||||
20 | demonstration. Such
demonstration may establish resource | ||||||
21 | standards that are not more
restrictive than those | ||||||
22 | established under Article IV of this Code.
| ||||||
23 | 6. (a) Subject to federal approval, children Children | ||||||
24 | younger than age 19 when countable income is at or below | ||||||
25 | 313% 133% of the federal poverty level , as determined by | ||||||
26 | the Department and in accordance with all applicable |
| |||||||
| |||||||
1 | federal requirements. The Department is authorized to | ||||||
2 | adopt emergency rules to implement the changes made to | ||||||
3 | this paragraph by this amendatory Act of the 102nd General | ||||||
4 | Assembly . Until September 30, 2019, or sooner if the | ||||||
5 | maintenance of effort requirements under the Patient | ||||||
6 | Protection and Affordable Care Act are eliminated or may | ||||||
7 | be waived before then, children younger than age 19 whose | ||||||
8 | countable monthly income, after the deduction of costs | ||||||
9 | incurred for medical care and for other types of remedial | ||||||
10 | care as specified in administrative rule, is equal to or | ||||||
11 | less than the Medical Assistance-No Grant(C) (MANG(C)) | ||||||
12 | Income Standard in effect on April 1, 2013 as set forth in | ||||||
13 | administrative rule. | ||||||
14 | (b) Children and youth who are under temporary custody | ||||||
15 | or guardianship of the Department of Children and Family | ||||||
16 | Services or who receive financial assistance in support of | ||||||
17 | an adoption or guardianship placement from the Department | ||||||
18 | of Children and Family Services.
| ||||||
19 | 7. (Blank).
| ||||||
20 | 8. As required under federal law, persons who are | ||||||
21 | eligible for Transitional Medical Assistance as a result | ||||||
22 | of an increase in earnings or child or spousal support | ||||||
23 | received. The plan for coverage for this class of persons | ||||||
24 | shall:
| ||||||
25 | (a) extend the medical assistance coverage to the | ||||||
26 | extent required by federal law; and
|
| |||||||
| |||||||
1 | (b) offer persons who have initially received 6 | ||||||
2 | months of the
coverage provided in paragraph (a) | ||||||
3 | above, the option of receiving an
additional 6 months | ||||||
4 | of coverage, subject to the following:
| ||||||
5 | (i) such coverage shall be pursuant to | ||||||
6 | provisions of the federal
Social Security Act;
| ||||||
7 | (ii) such coverage shall include all services | ||||||
8 | covered under Illinois' State Medicaid Plan;
| ||||||
9 | (iii) no premium shall be charged for such | ||||||
10 | coverage; and
| ||||||
11 | (iv) such coverage shall be suspended in the | ||||||
12 | event of a person's
failure without good cause to | ||||||
13 | file in a timely fashion reports required for
this | ||||||
14 | coverage under the Social Security Act and | ||||||
15 | coverage shall be reinstated
upon the filing of | ||||||
16 | such reports if the person remains otherwise | ||||||
17 | eligible.
| ||||||
18 | 9. Persons with acquired immunodeficiency syndrome | ||||||
19 | (AIDS) or with
AIDS-related conditions with respect to | ||||||
20 | whom there has been a determination
that but for home or | ||||||
21 | community-based services such individuals would
require | ||||||
22 | the level of care provided in an inpatient hospital, | ||||||
23 | skilled
nursing facility or intermediate care facility the | ||||||
24 | cost of which is
reimbursed under this Article. Assistance | ||||||
25 | shall be provided to such
persons to the maximum extent | ||||||
26 | permitted under Title
XIX of the Federal Social Security |
| |||||||
| |||||||
1 | Act.
| ||||||
2 | 10. Participants in the long-term care insurance | ||||||
3 | partnership program
established under the Illinois | ||||||
4 | Long-Term Care Partnership Program Act who meet the
| ||||||
5 | qualifications for protection of resources described in | ||||||
6 | Section 15 of that
Act.
| ||||||
7 | 11. Persons with disabilities who are employed and | ||||||
8 | eligible for Medicaid,
pursuant to Section | ||||||
9 | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, | ||||||
10 | subject to federal approval, persons with a medically | ||||||
11 | improved disability who are employed and eligible for | ||||||
12 | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | ||||||
13 | the Social Security Act, as
provided by the Illinois | ||||||
14 | Department by rule. In establishing eligibility standards | ||||||
15 | under this paragraph 11, the Department shall, subject to | ||||||
16 | federal approval: | ||||||
17 | (a) set the income eligibility standard at not | ||||||
18 | lower than 350% of the federal poverty level; | ||||||
19 | (b) exempt retirement accounts that the person | ||||||
20 | cannot access without penalty before the age
of 59 | ||||||
21 | 1/2, and medical savings accounts established pursuant | ||||||
22 | to 26 U.S.C. 220; | ||||||
23 | (c) allow non-exempt assets up to $25,000 as to | ||||||
24 | those assets accumulated during periods of eligibility | ||||||
25 | under this paragraph 11; and
| ||||||
26 | (d) continue to apply subparagraphs (b) and (c) in |
| |||||||
| |||||||
1 | determining the eligibility of the person under this | ||||||
2 | Article even if the person loses eligibility under | ||||||
3 | this paragraph 11.
| ||||||
4 | 12. Subject to federal approval, persons who are | ||||||
5 | eligible for medical
assistance coverage under applicable | ||||||
6 | provisions of the federal Social Security
Act and the | ||||||
7 | federal Breast and Cervical Cancer Prevention and | ||||||
8 | Treatment Act of
2000. Those eligible persons are defined | ||||||
9 | to include, but not be limited to,
the following persons:
| ||||||
10 | (1) persons who have been screened for breast or | ||||||
11 | cervical cancer under
the U.S. Centers for Disease | ||||||
12 | Control and Prevention Breast and Cervical Cancer
| ||||||
13 | Program established under Title XV of the federal | ||||||
14 | Public Health Service Services Act in
accordance with | ||||||
15 | the requirements of Section 1504 of that Act as | ||||||
16 | administered by
the Illinois Department of Public | ||||||
17 | Health; and
| ||||||
18 | (2) persons whose screenings under the above | ||||||
19 | program were funded in whole
or in part by funds | ||||||
20 | appropriated to the Illinois Department of Public | ||||||
21 | Health
for breast or cervical cancer screening.
| ||||||
22 | "Medical assistance" under this paragraph 12 shall be | ||||||
23 | identical to the benefits
provided under the State's | ||||||
24 | approved plan under Title XIX of the Social Security
Act. | ||||||
25 | The Department must request federal approval of the | ||||||
26 | coverage under this
paragraph 12 within 30 days after July |
| |||||||
| |||||||
1 | 3, 2001 ( the effective date of Public Act 92-47) this | ||||||
2 | amendatory Act of
the 92nd General Assembly .
| ||||||
3 | In addition to the persons who are eligible for | ||||||
4 | medical assistance pursuant to subparagraphs (1) and (2) | ||||||
5 | of this paragraph 12, and to be paid from funds | ||||||
6 | appropriated to the Department for its medical programs, | ||||||
7 | any uninsured person as defined by the Department in rules | ||||||
8 | residing in Illinois who is younger than 65 years of age, | ||||||
9 | who has been screened for breast and cervical cancer in | ||||||
10 | accordance with standards and procedures adopted by the | ||||||
11 | Department of Public Health for screening, and who is | ||||||
12 | referred to the Department by the Department of Public | ||||||
13 | Health as being in need of treatment for breast or | ||||||
14 | cervical cancer is eligible for medical assistance | ||||||
15 | benefits that are consistent with the benefits provided to | ||||||
16 | those persons described in subparagraphs (1) and (2). | ||||||
17 | Medical assistance coverage for the persons who are | ||||||
18 | eligible under the preceding sentence is not dependent on | ||||||
19 | federal approval, but federal moneys may be used to pay | ||||||
20 | for services provided under that coverage upon federal | ||||||
21 | approval. | ||||||
22 | 13. Subject to appropriation and to federal approval, | ||||||
23 | persons living with HIV/AIDS who are not otherwise | ||||||
24 | eligible under this Article and who qualify for services | ||||||
25 | covered under Section 5-5.04 as provided by the Illinois | ||||||
26 | Department by rule.
|
| |||||||
| |||||||
1 | 14. Subject to the availability of funds for this | ||||||
2 | purpose, the Department may provide coverage under this | ||||||
3 | Article to persons who reside in Illinois who are not | ||||||
4 | eligible under any of the preceding paragraphs and who | ||||||
5 | meet the income guidelines of paragraph 2(a) of this | ||||||
6 | Section and (i) have an application for asylum pending | ||||||
7 | before the federal Department of Homeland Security or on | ||||||
8 | appeal before a court of competent jurisdiction and are | ||||||
9 | represented either by counsel or by an advocate accredited | ||||||
10 | by the federal Department of Homeland Security and | ||||||
11 | employed by a not-for-profit organization in regard to | ||||||
12 | that application or appeal, or (ii) are receiving services | ||||||
13 | through a federally funded torture treatment center. | ||||||
14 | Medical coverage under this paragraph 14 may be provided | ||||||
15 | for up to 24 continuous months from the initial | ||||||
16 | eligibility date so long as an individual continues to | ||||||
17 | satisfy the criteria of this paragraph 14. If an | ||||||
18 | individual has an appeal pending regarding an application | ||||||
19 | for asylum before the Department of Homeland Security, | ||||||
20 | eligibility under this paragraph 14 may be extended until | ||||||
21 | a final decision is rendered on the appeal. The Department | ||||||
22 | may adopt rules governing the implementation of this | ||||||
23 | paragraph 14.
| ||||||
24 | 15. Family Care Eligibility. | ||||||
25 | (a) On and after July 1, 2012, a parent or other | ||||||
26 | caretaker relative who is 19 years of age or older when |
| |||||||
| |||||||
1 | countable income is at or below 133% of the federal | ||||||
2 | poverty level. A person may not spend down to become | ||||||
3 | eligible under this paragraph 15. | ||||||
4 | (b) Eligibility shall be reviewed annually. | ||||||
5 | (c) (Blank). | ||||||
6 | (d) (Blank). | ||||||
7 | (e) (Blank). | ||||||
8 | (f) (Blank). | ||||||
9 | (g) (Blank). | ||||||
10 | (h) (Blank). | ||||||
11 | (i) Following termination of an individual's | ||||||
12 | coverage under this paragraph 15, the individual must | ||||||
13 | be determined eligible before the person can be | ||||||
14 | re-enrolled. | ||||||
15 | 16. Subject to appropriation, uninsured persons who | ||||||
16 | are not otherwise eligible under this Section who have | ||||||
17 | been certified and referred by the Department of Public | ||||||
18 | Health as having been screened and found to need | ||||||
19 | diagnostic evaluation or treatment, or both diagnostic | ||||||
20 | evaluation and treatment, for prostate or testicular | ||||||
21 | cancer. For the purposes of this paragraph 16, uninsured | ||||||
22 | persons are those who do not have creditable coverage, as | ||||||
23 | defined under the Health Insurance Portability and | ||||||
24 | Accountability Act, or have otherwise exhausted any | ||||||
25 | insurance benefits they may have had, for prostate or | ||||||
26 | testicular cancer diagnostic evaluation or treatment, or |
| |||||||
| |||||||
1 | both diagnostic evaluation and treatment.
To be eligible, | ||||||
2 | a person must furnish a Social Security number.
A person's | ||||||
3 | assets are exempt from consideration in determining | ||||||
4 | eligibility under this paragraph 16.
Such persons shall be | ||||||
5 | eligible for medical assistance under this paragraph 16 | ||||||
6 | for so long as they need treatment for the cancer. A person | ||||||
7 | shall be considered to need treatment if, in the opinion | ||||||
8 | of the person's treating physician, the person requires | ||||||
9 | therapy directed toward cure or palliation of prostate or | ||||||
10 | testicular cancer, including recurrent metastatic cancer | ||||||
11 | that is a known or presumed complication of prostate or | ||||||
12 | testicular cancer and complications resulting from the | ||||||
13 | treatment modalities themselves. Persons who require only | ||||||
14 | routine monitoring services are not considered to need | ||||||
15 | treatment.
"Medical assistance" under this paragraph 16 | ||||||
16 | shall be identical to the benefits provided under the | ||||||
17 | State's approved plan under Title XIX of the Social | ||||||
18 | Security Act.
Notwithstanding any other provision of law, | ||||||
19 | the Department (i) does not have a claim against the | ||||||
20 | estate of a deceased recipient of services under this | ||||||
21 | paragraph 16 and (ii) does not have a lien against any | ||||||
22 | homestead property or other legal or equitable real | ||||||
23 | property interest owned by a recipient of services under | ||||||
24 | this paragraph 16. | ||||||
25 | 17. Persons who, pursuant to a waiver approved by the | ||||||
26 | Secretary of the U.S. Department of Health and Human |
| |||||||
| |||||||
1 | Services, are eligible for medical assistance under Title | ||||||
2 | XIX or XXI of the federal Social Security Act. | ||||||
3 | Notwithstanding any other provision of this Code and | ||||||
4 | consistent with the terms of the approved waiver, the | ||||||
5 | Illinois Department, may by rule: | ||||||
6 | (a) Limit the geographic areas in which the waiver | ||||||
7 | program operates. | ||||||
8 | (b) Determine the scope, quantity, duration, and | ||||||
9 | quality, and the rate and method of reimbursement, of | ||||||
10 | the medical services to be provided, which may differ | ||||||
11 | from those for other classes of persons eligible for | ||||||
12 | assistance under this Article. | ||||||
13 | (c) Restrict the persons' freedom in choice of | ||||||
14 | providers. | ||||||
15 | 18. Beginning January 1, 2014, persons aged 19 or | ||||||
16 | older, but younger than 65, who are not otherwise eligible | ||||||
17 | for medical assistance under this Section 5-2, who qualify | ||||||
18 | for medical assistance pursuant to 42 U.S.C. | ||||||
19 | 1396a(a)(10)(A)(i)(VIII) and applicable federal | ||||||
20 | regulations, and who have income at or below 133% of the | ||||||
21 | federal poverty level plus 5% for the applicable family | ||||||
22 | size as determined pursuant to 42 U.S.C. 1396a(e)(14) and | ||||||
23 | applicable federal regulations. Persons eligible for | ||||||
24 | medical assistance under this paragraph 18 shall receive | ||||||
25 | coverage for the Health Benefits Service Package as that | ||||||
26 | term is defined in subsection (m) of Section 5-1.1 of this |
| |||||||
| |||||||
1 | Code. If Illinois' federal medical assistance percentage | ||||||
2 | (FMAP) is reduced below 90% for persons eligible for | ||||||
3 | medical
assistance under this paragraph 18, eligibility | ||||||
4 | under this paragraph 18 shall cease no later than the end | ||||||
5 | of the third month following the month in which the | ||||||
6 | reduction in FMAP takes effect. | ||||||
7 | 19. Beginning January 1, 2014, as required under 42 | ||||||
8 | U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 | ||||||
9 | and younger than age 26 who are not otherwise eligible for | ||||||
10 | medical assistance under paragraphs (1) through (17) of | ||||||
11 | this Section who (i) were in foster care under the | ||||||
12 | responsibility of the State on the date of attaining age | ||||||
13 | 18 or on the date of attaining age 21 when a court has | ||||||
14 | continued wardship for good cause as provided in Section | ||||||
15 | 2-31 of the Juvenile Court Act of 1987 and (ii) received | ||||||
16 | medical assistance under the Illinois Title XIX State Plan | ||||||
17 | or waiver of such plan while in foster care. | ||||||
18 | 20. Beginning January 1, 2018, persons who are | ||||||
19 | foreign-born victims of human trafficking, torture, or | ||||||
20 | other serious crimes as defined in Section 2-19 of this | ||||||
21 | Code and their derivative family members if such persons: | ||||||
22 | (i) reside in Illinois; (ii) are not eligible under any of | ||||||
23 | the preceding paragraphs; (iii) meet the income guidelines | ||||||
24 | of subparagraph (a) of paragraph 2; and (iv) meet the | ||||||
25 | nonfinancial eligibility requirements of Sections 16-2, | ||||||
26 | 16-3, and 16-5 of this Code. The Department may extend |
| |||||||
| |||||||
1 | medical assistance for persons who are foreign-born | ||||||
2 | victims of human trafficking, torture, or other serious | ||||||
3 | crimes whose medical assistance would be terminated | ||||||
4 | pursuant to subsection (b) of Section 16-5 if the | ||||||
5 | Department determines that the person, during the year of | ||||||
6 | initial eligibility (1) experienced a health crisis, (2) | ||||||
7 | has been unable, after reasonable attempts, to obtain | ||||||
8 | necessary information from a third party, or (3) has other | ||||||
9 | extenuating circumstances that prevented the person from | ||||||
10 | completing his or her application for status. The | ||||||
11 | Department may adopt any rules necessary to implement the | ||||||
12 | provisions of this paragraph. | ||||||
13 | 21. Persons who are not otherwise eligible for medical | ||||||
14 | assistance under this Section who may qualify for medical | ||||||
15 | assistance pursuant to 42 U.S.C. | ||||||
16 | 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the | ||||||
17 | duration of any federal or State declared emergency due to | ||||||
18 | COVID-19. Medical assistance to persons eligible for | ||||||
19 | medical assistance solely pursuant to this paragraph 21 | ||||||
20 | shall be limited to any in vitro diagnostic product (and | ||||||
21 | the administration of such product) described in 42 U.S.C. | ||||||
22 | 1396d(a)(3)(B) on or after March 18, 2020, any visit | ||||||
23 | described in 42 U.S.C. 1396o(a)(2)(G), or any other | ||||||
24 | medical assistance that may be federally authorized for | ||||||
25 | this class of persons. The Department may also cover | ||||||
26 | treatment of COVID-19 for this class of persons, or any |
| |||||||
| |||||||
1 | similar category of uninsured individuals, to the extent | ||||||
2 | authorized under a federally approved 1115 Waiver or other | ||||||
3 | federal authority. Notwithstanding the provisions of | ||||||
4 | Section 1-11 of this Code, due to the nature of the | ||||||
5 | COVID-19 public health emergency, the Department may cover | ||||||
6 | and provide the medical assistance described in this | ||||||
7 | paragraph 21 to noncitizens who would otherwise meet the | ||||||
8 | eligibility requirements for the class of persons | ||||||
9 | described in this paragraph 21 for the duration of the | ||||||
10 | State emergency period. | ||||||
11 | In implementing the provisions of Public Act 96-20, the | ||||||
12 | Department is authorized to adopt only those rules necessary, | ||||||
13 | including emergency rules. Nothing in Public Act 96-20 permits | ||||||
14 | the Department to adopt rules or issue a decision that expands | ||||||
15 | eligibility for the FamilyCare Program to a person whose | ||||||
16 | income exceeds 185% of the Federal Poverty Level as determined | ||||||
17 | from time to time by the U.S. Department of Health and Human | ||||||
18 | Services, unless the Department is provided with express | ||||||
19 | statutory authority.
| ||||||
20 | The eligibility of any such person for medical assistance | ||||||
21 | under this
Article is not affected by the payment of any grant | ||||||
22 | under the Senior
Citizens and Persons with Disabilities | ||||||
23 | Property Tax Relief Act or any distributions or items of | ||||||
24 | income described under
subparagraph (X) of
paragraph (2) of | ||||||
25 | subsection (a) of Section 203 of the Illinois Income Tax
Act. | ||||||
26 | The Department shall by rule establish the amounts of
|
| |||||||
| |||||||
1 | assets to be disregarded in determining eligibility for | ||||||
2 | medical assistance,
which shall at a minimum equal the amounts | ||||||
3 | to be disregarded under the
Federal Supplemental Security | ||||||
4 | Income Program. The amount of assets of a
single person to be | ||||||
5 | disregarded
shall not be less than $2,000, and the amount of | ||||||
6 | assets of a married couple
to be disregarded shall not be less | ||||||
7 | than $3,000.
| ||||||
8 | To the extent permitted under federal law, any person | ||||||
9 | found guilty of a
second violation of Article VIIIA
shall be | ||||||
10 | ineligible for medical assistance under this Article, as | ||||||
11 | provided
in Section 8A-8.
| ||||||
12 | The eligibility of any person for medical assistance under | ||||||
13 | this Article
shall not be affected by the receipt by the person | ||||||
14 | of donations or benefits
from fundraisers held for the person | ||||||
15 | in cases of serious illness,
as long as neither the person nor | ||||||
16 | members of the person's family
have actual control over the | ||||||
17 | donations or benefits or the disbursement
of the donations or | ||||||
18 | benefits.
| ||||||
19 | Notwithstanding any other provision of this Code, if the | ||||||
20 | United States Supreme Court holds Title II, Subtitle A, | ||||||
21 | Section 2001(a) of Public Law 111-148 to be unconstitutional, | ||||||
22 | or if a holding of Public Law 111-148 makes Medicaid | ||||||
23 | eligibility allowed under Section 2001(a) inoperable, the | ||||||
24 | State or a unit of local government shall be prohibited from | ||||||
25 | enrolling individuals in the Medical Assistance Program as the | ||||||
26 | result of federal approval of a State Medicaid waiver on or |
| |||||||
| |||||||
1 | after June 14, 2012 ( the effective date of Public Act 97-687) | ||||||
2 | this amendatory Act of the 97th General Assembly , and any | ||||||
3 | individuals enrolled in the Medical Assistance Program | ||||||
4 | pursuant to eligibility permitted as a result of such a State | ||||||
5 | Medicaid waiver shall become immediately ineligible. | ||||||
6 | Notwithstanding any other provision of this Code, if an | ||||||
7 | Act of Congress that becomes a Public Law eliminates Section | ||||||
8 | 2001(a) of Public Law 111-148, the State or a unit of local | ||||||
9 | government shall be prohibited from enrolling individuals in | ||||||
10 | the Medical Assistance Program as the result of federal | ||||||
11 | approval of a State Medicaid waiver on or after June 14, 2012 | ||||||
12 | ( the effective date of Public Act 97-687) this amendatory Act | ||||||
13 | of the 97th General Assembly , and any individuals enrolled in | ||||||
14 | the Medical Assistance Program pursuant to eligibility | ||||||
15 | permitted as a result of such a State Medicaid waiver shall | ||||||
16 | become immediately ineligible. | ||||||
17 | Effective October 1, 2013, the determination of | ||||||
18 | eligibility of persons who qualify under paragraphs 5, 6, 8, | ||||||
19 | 15, 17, and 18 of this Section shall comply with the | ||||||
20 | requirements of 42 U.S.C. 1396a(e)(14) and applicable federal | ||||||
21 | regulations. | ||||||
22 | The Department of Healthcare and Family Services, the | ||||||
23 | Department of Human Services, and the Illinois health | ||||||
24 | insurance marketplace shall work cooperatively to assist | ||||||
25 | persons who would otherwise lose health benefits as a result | ||||||
26 | of changes made under Public Act 98-104 this amendatory Act of |
| |||||||
| |||||||
1 | the 98th General Assembly to transition to other health | ||||||
2 | insurance coverage. | ||||||
3 | (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; | ||||||
4 | revised 8-24-20.)
| ||||||
5 | (305 ILCS 5/11-4.2 new) | ||||||
6 | Sec. 11-4.2. Application assistance for enrolling | ||||||
7 | individuals in the medical assistance program. | ||||||
8 | (a) The Department shall have procedures to allow | ||||||
9 | application agents to assist in enrolling individuals in the | ||||||
10 | medical assistance program. As used in this Section, | ||||||
11 | "application agent" means an organization or individual, such | ||||||
12 | as a licensed health care provider, school, youth service | ||||||
13 | agency, employer, labor union, local chamber of commerce, | ||||||
14 | community-based organization, or other organization, approved | ||||||
15 | by the Department to assist in enrolling individuals in the | ||||||
16 | medical assistance program. | ||||||
17 | (b) At the Department's discretion, technical assistance | ||||||
18 | payments may be made available for approved applications | ||||||
19 | facilitated by an application agent. The Department shall | ||||||
20 | permit day and temporary labor service agencies, as defined in | ||||||
21 | the Day and Temporary Labor Services Act, doing business in | ||||||
22 | Illinois to enroll as unpaid application agents. As | ||||||
23 | established in the Free Healthcare Benefits Application | ||||||
24 | Assistance Act, it shall be unlawful for any person to charge | ||||||
25 | another person or family for assisting in completing and |
| |||||||
| |||||||
1 | submitting an application for enrollment in the medical | ||||||
2 | assistance program. | ||||||
3 | (c) Existing enrollment agreements or contracts for all | ||||||
4 | application agents, technical assistance payments, and | ||||||
5 | outreach grants that were authorized under Section 22 of the | ||||||
6 | Children's Health Insurance Program Act and Sections 25 and 30 | ||||||
7 | of the Covering ALL KIDS Health Insurance Act prior to those | ||||||
8 | Acts becoming inoperative shall continue to be authorized | ||||||
9 | under this Section per the terms of the agreement or contract | ||||||
10 | until modified, amended, or terminated.
| ||||||
11 | (305 ILCS 5/11-22d new) | ||||||
12 | Sec. 11-22d. Savings provisions. | ||||||
13 | (a) Notwithstanding any amendments or provisions in this | ||||||
14 | amendatory Act of the 102nd General Assembly which would make | ||||||
15 | the Children's Health Insurance Program Act or the Covering | ||||||
16 | ALL KIDS Health Insurance Act inoperative, Sections 11-22a, | ||||||
17 | 11-22b, and 11-22c of this Code shall remain in force for the | ||||||
18 | commencement or continuation of any cause of action that (i) | ||||||
19 | accrued prior to the effective date of this amendatory Act of | ||||||
20 | the 102nd General Assembly or the date upon which the | ||||||
21 | Department receives federal approval of the changes made to | ||||||
22 | paragraph (6) of Section 5-2 by this amendatory Act of the | ||||||
23 | 102nd General Assembly, whichever is later, and (ii) concerns | ||||||
24 | the recovery of any amount expended by the State for health | ||||||
25 | care benefits provided under the Children's Health Insurance |
| |||||||
| |||||||
1 | Program Act or the Covering ALL KIDS Health Insurance Act | ||||||
2 | prior to those Acts becoming inoperative. Any timely action | ||||||
3 | brought under Sections 11-22a, 11-22b, and 11-22c shall be | ||||||
4 | decided in accordance with those Sections as they existed when | ||||||
5 | the cause of action accrued. | ||||||
6 | (b) Notwithstanding any amendments or provisions in this | ||||||
7 | amendatory Act of the 102nd General Assembly which would make | ||||||
8 | the Children's Health Insurance Program Act or the Covering | ||||||
9 | ALL KIDS Health Insurance Act inoperative, paragraph (2) of | ||||||
10 | Section 12-9 of this Code shall remain in force as to | ||||||
11 | recoveries made by the Department of Healthcare and Family | ||||||
12 | Services from any cause of action commenced or continued in | ||||||
13 | accordance with subsection (a).
| ||||||
14 | (305 ILCS 5/11-32 new) | ||||||
15 | Sec. 11-32. Premium debts; forgiveness, compromise, | ||||||
16 | reduction. The Department may forgive, compromise, or reduce | ||||||
17 | any debt owed by a former or current recipient of medical | ||||||
18 | assistance under this Code or health care benefits under the | ||||||
19 | Children's Health Insurance Program or the Covering ALL KIDS | ||||||
20 | Health Insurance Program that is related to any premium that | ||||||
21 | was determined or imposed in accordance with (i) the | ||||||
22 | Children's Health Insurance Program Act or the Covering ALL | ||||||
23 | KIDS Health Insurance Act prior to those Acts becoming | ||||||
24 | inoperative or (ii) any corresponding administrative rule.
|
| |||||||
| |||||||
1 | (305 ILCS 5/12-4.35)
| ||||||
2 | Sec. 12-4.35. Medical services for certain noncitizens.
| ||||||
3 | (a) Notwithstanding
Section 1-11 of this Code or Section | ||||||
4 | 20(a) of the Children's Health Insurance
Program Act, the | ||||||
5 | Department of Healthcare and Family Services may provide | ||||||
6 | medical services to
noncitizens who have not yet attained 19 | ||||||
7 | years of age and who are not eligible
for medical assistance | ||||||
8 | under Article V of this Code or under the Children's
Health | ||||||
9 | Insurance Program created by the Children's Health Insurance | ||||||
10 | Program Act
due to their not meeting the otherwise applicable | ||||||
11 | provisions of Section 1-11
of this Code or Section 20(a) of the | ||||||
12 | Children's Health Insurance Program Act.
The medical services | ||||||
13 | available, standards for eligibility, and other conditions
of | ||||||
14 | participation under this Section shall be established by rule | ||||||
15 | by the
Department; however, any such rule shall be at least as | ||||||
16 | restrictive as the
rules for medical assistance under Article | ||||||
17 | V of this Code or the Children's
Health Insurance Program | ||||||
18 | created by the Children's Health Insurance Program
Act.
| ||||||
19 | (a-5) Notwithstanding Section 1-11 of this Code, the | ||||||
20 | Department of Healthcare and Family Services may provide | ||||||
21 | medical assistance in accordance with Article V of this Code | ||||||
22 | to noncitizens over the age of 65 years of age who are not | ||||||
23 | eligible for medical assistance under Article V of this Code | ||||||
24 | due to their not meeting the otherwise applicable provisions | ||||||
25 | of Section 1-11 of this Code, whose income is at or below 100% | ||||||
26 | of the federal poverty level after deducting the costs of |
| |||||||
| |||||||
1 | medical or other remedial care, and who would otherwise meet | ||||||
2 | the eligibility requirements in Section 5-2 of this Code. The | ||||||
3 | medical services available, standards for eligibility, and | ||||||
4 | other conditions of participation under this Section shall be | ||||||
5 | established by rule by the Department; however, any such rule | ||||||
6 | shall be at least as restrictive as the rules for medical | ||||||
7 | assistance under Article V of this Code. | ||||||
8 | (b) The Department is authorized to take any action that | ||||||
9 | would not otherwise be prohibited by applicable law , including | ||||||
10 | without
limitation cessation or limitation of enrollment, | ||||||
11 | reduction of available medical services,
and changing | ||||||
12 | standards for eligibility, that is deemed necessary by the
| ||||||
13 | Department during a State fiscal year to assure that payments | ||||||
14 | under this
Section do not exceed available funds.
| ||||||
15 | (c) (Blank). Continued enrollment of
individuals into the | ||||||
16 | program created under subsection (a) of this Section in any | ||||||
17 | fiscal year is
contingent upon continued enrollment of | ||||||
18 | individuals into the Children's Health
Insurance Program | ||||||
19 | during that fiscal year.
| ||||||
20 | (d) (Blank).
| ||||||
21 | (Source: P.A. 101-636, eff. 6-10-20.)
| ||||||
22 | Article 30. | ||||||
23 | Section 30-5. The Illinois Public Aid Code is amended by | ||||||
24 | changing Sections 5-5 and 5-5f as follows:
|
| |||||||
| |||||||
1 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
2 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
3 | rule, shall
determine the quantity and quality of and the rate | ||||||
4 | of reimbursement for the
medical assistance for which
payment | ||||||
5 | will be authorized, and the medical services to be provided,
| ||||||
6 | which may include all or part of the following: (1) inpatient | ||||||
7 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
8 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
9 | services; (5) physicians'
services whether furnished in the | ||||||
10 | office, the patient's home, a
hospital, a skilled nursing | ||||||
11 | home, or elsewhere; (6) medical care, or any
other type of | ||||||
12 | remedial care furnished by licensed practitioners; (7)
home | ||||||
13 | health care services; (8) private duty nursing service; (9) | ||||||
14 | clinic
services; (10) dental services, including prevention | ||||||
15 | and treatment of periodontal disease and dental caries disease | ||||||
16 | for pregnant women, provided by an individual licensed to | ||||||
17 | practice dentistry or dental surgery; for purposes of this | ||||||
18 | item (10), "dental services" means diagnostic, preventive, or | ||||||
19 | corrective procedures provided by or under the supervision of | ||||||
20 | a dentist in the practice of his or her profession; (11) | ||||||
21 | physical therapy and related
services; (12) prescribed drugs, | ||||||
22 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
23 | a physician skilled in the diseases of the eye,
or by an | ||||||
24 | optometrist, whichever the person may select; (13) other
| ||||||
25 | diagnostic, screening, preventive, and rehabilitative |
| |||||||
| |||||||
1 | services, including to ensure that the individual's need for | ||||||
2 | intervention or treatment of mental disorders or substance use | ||||||
3 | disorders or co-occurring mental health and substance use | ||||||
4 | disorders is determined using a uniform screening, assessment, | ||||||
5 | and evaluation process inclusive of criteria, for children and | ||||||
6 | adults; for purposes of this item (13), a uniform screening, | ||||||
7 | assessment, and evaluation process refers to a process that | ||||||
8 | includes an appropriate evaluation and, as warranted, a | ||||||
9 | referral; "uniform" does not mean the use of a singular | ||||||
10 | instrument, tool, or process that all must utilize; (14)
| ||||||
11 | transportation and such other expenses as may be necessary; | ||||||
12 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
13 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
14 | Treatment Act, for
injuries sustained as a result of the | ||||||
15 | sexual assault, including
examinations and laboratory tests to | ||||||
16 | discover evidence which may be used in
criminal proceedings | ||||||
17 | arising from the sexual assault; (16) the
diagnosis and | ||||||
18 | treatment of sickle cell anemia; (16.5) services performed by | ||||||
19 | a chiropractic physician licensed under the Medical Practice | ||||||
20 | Act of 1987 and acting within the scope of his or her license, | ||||||
21 | including, but not limited to, chiropractic manipulative | ||||||
22 | treatment; and (17)
any other medical care, and any other type | ||||||
23 | of remedial care recognized
under the laws of this State. The | ||||||
24 | term "any other type of remedial care" shall
include nursing | ||||||
25 | care and nursing home service for persons who rely on
| ||||||
26 | treatment by spiritual means alone through prayer for healing.
|
| |||||||
| |||||||
1 | Notwithstanding any other provision of this Section, a | ||||||
2 | comprehensive
tobacco use cessation program that includes | ||||||
3 | purchasing prescription drugs or
prescription medical devices | ||||||
4 | approved by the Food and Drug Administration shall
be covered | ||||||
5 | under the medical assistance
program under this Article for | ||||||
6 | persons who are otherwise eligible for
assistance under this | ||||||
7 | Article.
| ||||||
8 | Notwithstanding any other provision of this Code, | ||||||
9 | reproductive health care that is otherwise legal in Illinois | ||||||
10 | shall be covered under the medical assistance program for | ||||||
11 | persons who are otherwise eligible for medical assistance | ||||||
12 | under this Article. | ||||||
13 | Notwithstanding any other provision of this Code, the | ||||||
14 | Illinois
Department may not require, as a condition of payment | ||||||
15 | for any laboratory
test authorized under this Article, that a | ||||||
16 | physician's handwritten signature
appear on the laboratory | ||||||
17 | test order form. The Illinois Department may,
however, impose | ||||||
18 | other appropriate requirements regarding laboratory test
order | ||||||
19 | documentation.
| ||||||
20 | Upon receipt of federal approval of an amendment to the | ||||||
21 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
22 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
23 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
24 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
25 | that its vendor or vendors are enrolled as providers in the | ||||||
26 | medical assistance program and in any capitated Medicaid |
| |||||||
| |||||||
1 | managed care entity (MCE) serving individuals enrolled in a | ||||||
2 | school within the CPS system. Under any contract procured | ||||||
3 | under this provision, the vendor or vendors must serve only | ||||||
4 | individuals enrolled in a school within the CPS system. Claims | ||||||
5 | for services provided by CPS's vendor or vendors to recipients | ||||||
6 | of benefits in the medical assistance program under this Code, | ||||||
7 | the Children's Health Insurance Program, or the Covering ALL | ||||||
8 | KIDS Health Insurance Program shall be submitted to the | ||||||
9 | Department or the MCE in which the individual is enrolled for | ||||||
10 | payment and shall be reimbursed at the Department's or the | ||||||
11 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
12 | On and after July 1, 2012, the Department of Healthcare | ||||||
13 | and Family Services may provide the following services to
| ||||||
14 | persons
eligible for assistance under this Article who are | ||||||
15 | participating in
education, training or employment programs | ||||||
16 | operated by the Department of Human
Services as successor to | ||||||
17 | the Department of Public Aid:
| ||||||
18 | (1) dental services provided by or under the | ||||||
19 | supervision of a dentist; and
| ||||||
20 | (2) eyeglasses prescribed by a physician skilled in | ||||||
21 | the diseases of the
eye, or by an optometrist, whichever | ||||||
22 | the person may select.
| ||||||
23 | On and after July 1, 2018, the Department of Healthcare | ||||||
24 | and Family Services shall provide dental services to any adult | ||||||
25 | who is otherwise eligible for assistance under the medical | ||||||
26 | assistance program. As used in this paragraph, "dental |
| |||||||
| |||||||
1 | services" means diagnostic, preventative, restorative, or | ||||||
2 | corrective procedures, including procedures and services for | ||||||
3 | the prevention and treatment of periodontal disease and dental | ||||||
4 | caries disease, provided by an individual who is licensed to | ||||||
5 | practice dentistry or dental surgery or who is under the | ||||||
6 | supervision of a dentist in the practice of his or her | ||||||
7 | profession. | ||||||
8 | On and after July 1, 2018, targeted dental services, as | ||||||
9 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
10 | United States District Court for the Northern District of | ||||||
11 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
12 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
13 | the medical assistance program shall be established at no less | ||||||
14 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
15 | of the Consent Decree for targeted dental services that are | ||||||
16 | provided to persons under the age of 18 under the medical | ||||||
17 | assistance program. | ||||||
18 | Notwithstanding any other provision of this Code and | ||||||
19 | subject to federal approval, the Department may adopt rules to | ||||||
20 | allow a dentist who is volunteering his or her service at no | ||||||
21 | cost to render dental services through an enrolled | ||||||
22 | not-for-profit health clinic without the dentist personally | ||||||
23 | enrolling as a participating provider in the medical | ||||||
24 | assistance program. A not-for-profit health clinic shall | ||||||
25 | include a public health clinic or Federally Qualified Health | ||||||
26 | Center or other enrolled provider, as determined by the |
| |||||||
| |||||||
1 | Department, through which dental services covered under this | ||||||
2 | Section are performed. The Department shall establish a | ||||||
3 | process for payment of claims for reimbursement for covered | ||||||
4 | dental services rendered under this provision. | ||||||
5 | The Illinois Department, by rule, may distinguish and | ||||||
6 | classify the
medical services to be provided only in | ||||||
7 | accordance with the classes of
persons designated in Section | ||||||
8 | 5-2.
| ||||||
9 | The Department of Healthcare and Family Services must | ||||||
10 | provide coverage and reimbursement for amino acid-based | ||||||
11 | elemental formulas, regardless of delivery method, for the | ||||||
12 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
13 | short bowel syndrome when the prescribing physician has issued | ||||||
14 | a written order stating that the amino acid-based elemental | ||||||
15 | formula is medically necessary.
| ||||||
16 | The Illinois Department shall authorize the provision of, | ||||||
17 | and shall
authorize payment for, screening by low-dose | ||||||
18 | mammography for the presence of
occult breast cancer for women | ||||||
19 | 35 years of age or older who are eligible
for medical | ||||||
20 | assistance under this Article, as follows: | ||||||
21 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
22 | age.
| ||||||
23 | (B) An annual mammogram for women 40 years of age or | ||||||
24 | older. | ||||||
25 | (C) A mammogram at the age and intervals considered | ||||||
26 | medically necessary by the woman's health care provider |
| |||||||
| |||||||
1 | for women under 40 years of age and having a family history | ||||||
2 | of breast cancer, prior personal history of breast cancer, | ||||||
3 | positive genetic testing, or other risk factors. | ||||||
4 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
5 | entire breast or breasts if a mammogram demonstrates | ||||||
6 | heterogeneous or dense breast tissue or when medically | ||||||
7 | necessary as determined by a physician licensed to | ||||||
8 | practice medicine in all of its branches. | ||||||
9 | (E) A screening MRI when medically necessary, as | ||||||
10 | determined by a physician licensed to practice medicine in | ||||||
11 | all of its branches. | ||||||
12 | (F) A diagnostic mammogram when medically necessary, | ||||||
13 | as determined by a physician licensed to practice medicine | ||||||
14 | in all its branches, advanced practice registered nurse, | ||||||
15 | or physician assistant. | ||||||
16 | The Department shall not impose a deductible, coinsurance, | ||||||
17 | copayment, or any other cost-sharing requirement on the | ||||||
18 | coverage provided under this paragraph; except that this | ||||||
19 | sentence does not apply to coverage of diagnostic mammograms | ||||||
20 | to the extent such coverage would disqualify a high-deductible | ||||||
21 | health plan from eligibility for a health savings account | ||||||
22 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
23 | U.S.C. 223). | ||||||
24 | All screenings
shall
include a physical breast exam, | ||||||
25 | instruction on self-examination and
information regarding the | ||||||
26 | frequency of self-examination and its value as a
preventative |
| |||||||
| |||||||
1 | tool. | ||||||
2 | For purposes of this Section: | ||||||
3 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
4 | diagnostic mammography. | ||||||
5 | "Diagnostic
mammography" means a method of screening that | ||||||
6 | is designed to
evaluate an abnormality in a breast, including | ||||||
7 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
8 | subjective or objective
abnormality otherwise detected in the | ||||||
9 | breast. | ||||||
10 | "Low-dose mammography" means
the x-ray examination of the | ||||||
11 | breast using equipment dedicated specifically
for mammography, | ||||||
12 | including the x-ray tube, filter, compression device,
and | ||||||
13 | image receptor, with an average radiation exposure delivery
of | ||||||
14 | less than one rad per breast for 2 views of an average size | ||||||
15 | breast.
The term also includes digital mammography and | ||||||
16 | includes breast tomosynthesis. | ||||||
17 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
18 | involves the acquisition of projection images over the | ||||||
19 | stationary breast to produce cross-sectional digital | ||||||
20 | three-dimensional images of the breast. | ||||||
21 | If, at any time, the Secretary of the United States | ||||||
22 | Department of Health and Human Services, or its successor | ||||||
23 | agency, promulgates rules or regulations to be published in | ||||||
24 | the Federal Register or publishes a comment in the Federal | ||||||
25 | Register or issues an opinion, guidance, or other action that | ||||||
26 | would require the State, pursuant to any provision of the |
| |||||||
| |||||||
1 | Patient Protection and Affordable Care Act (Public Law | ||||||
2 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
3 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
4 | of any coverage for breast tomosynthesis outlined in this | ||||||
5 | paragraph, then the requirement that an insurer cover breast | ||||||
6 | tomosynthesis is inoperative other than any such coverage | ||||||
7 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
8 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
9 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
10 | this paragraph.
| ||||||
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 | ||||||
14 | Imaging Excellence as certified by the American College of | ||||||
15 | Radiology. | ||||||
16 | On and after January 1, 2012, providers participating in a | ||||||
17 | quality improvement program approved by the Department shall | ||||||
18 | be reimbursed for screening and diagnostic mammography at the | ||||||
19 | same rate as the Medicare program's rates, including the | ||||||
20 | increased reimbursement for digital mammography. | ||||||
21 | The Department shall convene an expert panel including | ||||||
22 | representatives of hospitals, free-standing mammography | ||||||
23 | facilities, and doctors, including radiologists, to establish | ||||||
24 | quality standards for mammography. | ||||||
25 | On and after January 1, 2017, providers participating in a | ||||||
26 | breast cancer treatment quality improvement program approved |
| |||||||
| |||||||
1 | by the Department shall be reimbursed for breast cancer | ||||||
2 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
3 | program's rates for the data elements included in the breast | ||||||
4 | cancer treatment quality program. | ||||||
5 | The Department shall convene an expert panel, including | ||||||
6 | representatives of hospitals, free-standing breast cancer | ||||||
7 | treatment centers, breast cancer quality organizations, and | ||||||
8 | doctors, including breast surgeons, reconstructive breast | ||||||
9 | surgeons, oncologists, and primary care providers to establish | ||||||
10 | quality standards for breast cancer treatment. | ||||||
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. By January 1, 2016, the | ||||||
16 | Department shall report to the General Assembly on the status | ||||||
17 | of the provision set forth in this paragraph. | ||||||
18 | The Department shall establish a methodology to remind | ||||||
19 | women who are age-appropriate for screening mammography, but | ||||||
20 | who have not received a mammogram within the previous 18 | ||||||
21 | months, of the importance and benefit of screening | ||||||
22 | mammography. The Department shall work with experts in breast | ||||||
23 | cancer outreach and patient navigation to optimize these | ||||||
24 | reminders and shall establish a methodology for evaluating | ||||||
25 | their effectiveness and modifying the methodology based on the | ||||||
26 | evaluation. |
| |||||||
| |||||||
1 | The Department shall establish a performance goal for | ||||||
2 | primary care providers with respect to their female patients | ||||||
3 | over age 40 receiving an annual mammogram. This performance | ||||||
4 | goal shall be used to provide additional reimbursement in the | ||||||
5 | form of a quality performance bonus to primary care providers | ||||||
6 | who meet that goal. | ||||||
7 | The Department shall devise a means of case-managing or | ||||||
8 | patient navigation for beneficiaries diagnosed with breast | ||||||
9 | cancer. This program shall initially operate as a pilot | ||||||
10 | program in areas of the State with the highest incidence of | ||||||
11 | mortality related to breast cancer. At least one pilot program | ||||||
12 | site shall be in the metropolitan Chicago area and at least one | ||||||
13 | site shall be outside the metropolitan Chicago area. On or | ||||||
14 | after July 1, 2016, the pilot program shall be expanded to | ||||||
15 | include one site in western Illinois, one site in southern | ||||||
16 | Illinois, one site in central Illinois, and 4 sites within | ||||||
17 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
18 | be carried out measuring health outcomes and cost of care for | ||||||
19 | those served by the pilot program compared to similarly | ||||||
20 | situated patients who are not served by the pilot program. | ||||||
21 | The Department shall require all networks of care to | ||||||
22 | develop a means either internally or by contract with experts | ||||||
23 | in navigation and community outreach to navigate cancer | ||||||
24 | patients to comprehensive care in a timely fashion. The | ||||||
25 | Department shall require all networks of care to include | ||||||
26 | access for patients diagnosed with cancer to at least one |
| |||||||
| |||||||
1 | academic commission on cancer-accredited cancer program as an | ||||||
2 | in-network covered benefit. | ||||||
3 | Any medical or health care provider shall immediately | ||||||
4 | recommend, to
any pregnant woman who is being provided | ||||||
5 | prenatal services and is suspected
of having a substance use | ||||||
6 | disorder as defined in the Substance Use Disorder Act, | ||||||
7 | referral to a local substance use disorder treatment program | ||||||
8 | licensed by the Department of Human Services or to a licensed
| ||||||
9 | hospital which provides substance abuse treatment services. | ||||||
10 | The Department of Healthcare and Family Services
shall assure | ||||||
11 | coverage for the cost of treatment of the drug abuse or
| ||||||
12 | addiction for pregnant recipients in accordance with the | ||||||
13 | Illinois Medicaid
Program in conjunction with the Department | ||||||
14 | of Human Services.
| ||||||
15 | All medical providers providing medical assistance to | ||||||
16 | pregnant women
under this Code shall receive information from | ||||||
17 | the Department on the
availability of services under any
| ||||||
18 | program providing case management services for addicted women,
| ||||||
19 | including information on appropriate referrals for other | ||||||
20 | social services
that may be needed by addicted women in | ||||||
21 | addition to treatment 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 | ||||||
25 | a public awareness campaign, may
provide information | ||||||
26 | concerning treatment for alcoholism and drug abuse and
|
| |||||||
| |||||||
1 | addiction, prenatal health care, and other pertinent programs | ||||||
2 | directed at
reducing the number of drug-affected infants born | ||||||
3 | to recipients of 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 | ||||||
20 | projects in certain geographic areas. The Partnership shall
be | ||||||
21 | represented by a sponsor organization. The Department, by | ||||||
22 | rule, shall
develop qualifications for sponsors of | ||||||
23 | Partnerships. Nothing in this
Section shall be construed to | ||||||
24 | require that the sponsor organization be a
medical | ||||||
25 | organization.
| ||||||
26 | The sponsor must negotiate formal written contracts with |
| |||||||
| |||||||
1 | medical
providers for physician services, inpatient and | ||||||
2 | outpatient hospital care,
home health services, treatment for | ||||||
3 | alcoholism and substance abuse, and
other services determined | ||||||
4 | necessary by the Illinois Department by rule for
delivery by | ||||||
5 | Partnerships. Physician services must include prenatal and
| ||||||
6 | obstetrical care. The Illinois Department shall reimburse | ||||||
7 | medical services
delivered by Partnership providers to clients | ||||||
8 | in target areas according to
provisions of this Article and | ||||||
9 | the Illinois Health Finance Reform Act,
except that:
| ||||||
10 | (1) Physicians participating in a Partnership and | ||||||
11 | providing certain
services, which shall be determined by | ||||||
12 | the Illinois Department, to persons
in areas covered by | ||||||
13 | the Partnership may receive an additional surcharge
for | ||||||
14 | such services.
| ||||||
15 | (2) The Department may elect to consider and negotiate | ||||||
16 | financial
incentives to encourage the development of | ||||||
17 | Partnerships and the efficient
delivery of medical care.
| ||||||
18 | (3) Persons receiving medical services through | ||||||
19 | Partnerships may receive
medical and case management | ||||||
20 | services above the level usually offered
through the | ||||||
21 | medical assistance program.
| ||||||
22 | Medical providers shall be required to meet certain | ||||||
23 | qualifications to
participate in Partnerships to ensure the | ||||||
24 | delivery of high quality medical
services. These | ||||||
25 | qualifications shall be determined by rule of the Illinois
| ||||||
26 | Department and may be higher than qualifications for |
| |||||||
| |||||||
1 | participation in the
medical assistance program. Partnership | ||||||
2 | sponsors may prescribe reasonable
additional qualifications | ||||||
3 | for participation by medical providers, only with
the prior | ||||||
4 | written approval of the Illinois Department.
| ||||||
5 | Nothing in this Section shall limit the free choice of | ||||||
6 | practitioners,
hospitals, and other providers of medical | ||||||
7 | services by clients.
In order to ensure patient freedom of | ||||||
8 | choice, the Illinois Department shall
immediately promulgate | ||||||
9 | all rules and take all other necessary actions so that
| ||||||
10 | provided services may be accessed from therapeutically | ||||||
11 | certified optometrists
to the full extent of the Illinois | ||||||
12 | Optometric Practice Act of 1987 without
discriminating between | ||||||
13 | service providers.
| ||||||
14 | The Department shall apply for a waiver from the United | ||||||
15 | States Health
Care Financing Administration to allow for the | ||||||
16 | implementation of
Partnerships under this Section.
| ||||||
17 | The Illinois Department shall require health care | ||||||
18 | providers to maintain
records that document the medical care | ||||||
19 | and services provided to recipients
of Medical Assistance | ||||||
20 | under this Article. Such records must be retained for a period | ||||||
21 | of not less than 6 years from the date of service or as | ||||||
22 | provided by applicable State law, whichever period is longer, | ||||||
23 | except that if an audit is initiated within the required | ||||||
24 | retention period then the records must be retained until the | ||||||
25 | audit is completed and every exception is resolved. The | ||||||
26 | Illinois Department shall
require health care providers to |
| |||||||
| |||||||
1 | make available, when authorized by the
patient, in writing, | ||||||
2 | the medical records in a timely fashion to other
health care | ||||||
3 | providers who are treating or serving persons eligible for
| ||||||
4 | Medical Assistance under this Article. All dispensers of | ||||||
5 | medical services
shall be required to maintain and retain | ||||||
6 | business and professional records
sufficient to fully and | ||||||
7 | accurately document the nature, scope, details and
receipt of | ||||||
8 | the health care provided to persons eligible for medical
| ||||||
9 | assistance under this Code, in accordance with regulations | ||||||
10 | promulgated by
the Illinois Department. The rules and | ||||||
11 | regulations shall require that proof
of the receipt of | ||||||
12 | prescription drugs, dentures, prosthetic devices and
| ||||||
13 | eyeglasses by eligible persons under this Section accompany | ||||||
14 | each claim
for reimbursement submitted by the dispenser of | ||||||
15 | such medical services.
No such claims for reimbursement shall | ||||||
16 | be approved for payment by the Illinois
Department without | ||||||
17 | such proof of receipt, unless the Illinois Department
shall | ||||||
18 | have put into effect and shall be operating a system of | ||||||
19 | post-payment
audit and review which shall, on a sampling | ||||||
20 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
21 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
22 | for which payment is being made are actually being
received by | ||||||
23 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
24 | (the effective date of Public Act 83-1439), the Illinois | ||||||
25 | Department shall establish a
current list of acquisition costs | ||||||
26 | for all prosthetic devices and any
other items recognized as |
| |||||||
| |||||||
1 | medical equipment and supplies reimbursable under
this Article | ||||||
2 | and shall update such list on a quarterly basis, except that
| ||||||
3 | the acquisition costs of all prescription drugs shall be | ||||||
4 | updated no
less frequently than every 30 days as required by | ||||||
5 | Section 5-5.12.
| ||||||
6 | Notwithstanding any other law to the contrary, the | ||||||
7 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
8 | (the effective date of Public Act 98-104), establish | ||||||
9 | procedures to permit skilled care facilities licensed under | ||||||
10 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
11 | reimbursement purposes. Following development of these | ||||||
12 | procedures, the Department shall, by July 1, 2016, test the | ||||||
13 | viability of the new system and implement any necessary | ||||||
14 | operational or structural changes to its information | ||||||
15 | technology platforms in order to allow for the direct | ||||||
16 | acceptance and payment of nursing home claims. | ||||||
17 | Notwithstanding any other law to the contrary, the | ||||||
18 | Illinois Department shall, within 365 days after August 15, | ||||||
19 | 2014 (the effective date of Public Act 98-963), establish | ||||||
20 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
21 | Community Care Act and MC/DD facilities licensed under the | ||||||
22 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
23 | purposes. Following development of these procedures, the | ||||||
24 | Department shall have an additional 365 days to test the | ||||||
25 | viability of the new system and to ensure that any necessary | ||||||
26 | operational or structural changes to its information |
| |||||||
| |||||||
1 | technology platforms are implemented. | ||||||
2 | The Illinois Department shall require all dispensers of | ||||||
3 | medical
services, other than an individual practitioner or | ||||||
4 | group of practitioners,
desiring to participate in the Medical | ||||||
5 | Assistance program
established under this Article to disclose | ||||||
6 | all financial, beneficial,
ownership, equity, surety or other | ||||||
7 | interests in any and all firms,
corporations, partnerships, | ||||||
8 | associations, business enterprises, joint
ventures, agencies, | ||||||
9 | institutions or other legal entities providing any
form of | ||||||
10 | health care services in this State under this Article.
| ||||||
11 | The Illinois Department may require that all dispensers of | ||||||
12 | medical
services desiring to participate in the medical | ||||||
13 | assistance program
established under this Article disclose, | ||||||
14 | under such terms and conditions as
the Illinois Department may | ||||||
15 | by rule establish, all inquiries from clients
and attorneys | ||||||
16 | regarding medical bills paid by the Illinois Department, which
| ||||||
17 | inquiries could indicate potential existence of claims or | ||||||
18 | liens for the
Illinois Department.
| ||||||
19 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
20 | period and shall be conditional for one year. During the | ||||||
21 | period of conditional enrollment, the Department may
terminate | ||||||
22 | the vendor's eligibility to participate in, or may disenroll | ||||||
23 | the vendor from, the medical assistance
program without cause. | ||||||
24 | Unless otherwise specified, such termination of eligibility or | ||||||
25 | disenrollment is not subject to the
Department's hearing | ||||||
26 | process.
However, a disenrolled vendor may reapply without |
| |||||||
| |||||||
1 | penalty.
| ||||||
2 | The Department has the discretion to limit the conditional | ||||||
3 | enrollment period for vendors based upon category of risk of | ||||||
4 | the vendor. | ||||||
5 | Prior to enrollment and during the conditional enrollment | ||||||
6 | period in the medical assistance program, all vendors shall be | ||||||
7 | subject to enhanced oversight, screening, and review based on | ||||||
8 | the risk of fraud, waste, and abuse that is posed by the | ||||||
9 | category of risk of the vendor. The Illinois Department shall | ||||||
10 | establish the procedures for oversight, screening, and review, | ||||||
11 | which may include, but need not be limited to: criminal and | ||||||
12 | financial background checks; fingerprinting; license, | ||||||
13 | certification, and authorization verifications; unscheduled or | ||||||
14 | unannounced site visits; database checks; prepayment audit | ||||||
15 | reviews; audits; payment caps; payment suspensions; and other | ||||||
16 | screening as required by federal or State law. | ||||||
17 | The Department shall define or specify the following: (i) | ||||||
18 | by provider notice, the "category of risk of the vendor" for | ||||||
19 | each type of vendor, which shall take into account the level of | ||||||
20 | screening applicable to a particular category of vendor under | ||||||
21 | federal law and regulations; (ii) by rule or provider notice, | ||||||
22 | the maximum length of the conditional enrollment period for | ||||||
23 | each category of risk of the vendor; and (iii) by rule, the | ||||||
24 | hearing rights, if any, afforded to a vendor in each category | ||||||
25 | of risk of the vendor that is terminated or disenrolled during | ||||||
26 | the conditional enrollment period. |
| |||||||
| |||||||
1 | To be eligible for payment consideration, a vendor's | ||||||
2 | payment claim or bill, either as an initial claim or as a | ||||||
3 | resubmitted claim following prior rejection, must be received | ||||||
4 | by the Illinois Department, or its fiscal intermediary, no | ||||||
5 | later than 180 days after the latest date on the claim on which | ||||||
6 | medical goods or services were provided, with the following | ||||||
7 | exceptions: | ||||||
8 | (1) In the case of a provider whose enrollment is in | ||||||
9 | process by the Illinois Department, the 180-day period | ||||||
10 | shall not begin until the date on the written notice from | ||||||
11 | the Illinois Department that the provider enrollment is | ||||||
12 | complete. | ||||||
13 | (2) In the case of errors attributable to the Illinois | ||||||
14 | Department or any of its claims processing intermediaries | ||||||
15 | which result in an inability to receive, process, or | ||||||
16 | adjudicate a claim, the 180-day period shall not begin | ||||||
17 | until the provider has been notified of the error. | ||||||
18 | (3) In the case of a provider for whom the Illinois | ||||||
19 | Department initiates the monthly billing process. | ||||||
20 | (4) In the case of a provider operated by a unit of | ||||||
21 | local government with a population exceeding 3,000,000 | ||||||
22 | when local government funds finance federal participation | ||||||
23 | for claims payments. | ||||||
24 | For claims for services rendered during a period for which | ||||||
25 | a recipient received retroactive eligibility, claims must be | ||||||
26 | filed within 180 days after the Department determines the |
| |||||||
| |||||||
1 | applicant is eligible. For claims for which the Illinois | ||||||
2 | Department is not the primary payer, claims must be submitted | ||||||
3 | to the Illinois Department within 180 days after the final | ||||||
4 | adjudication by the primary payer. | ||||||
5 | In the case of long term care facilities, within 45 | ||||||
6 | calendar days of receipt by the facility of required | ||||||
7 | prescreening information, new admissions with associated | ||||||
8 | admission documents shall be submitted through the Medical | ||||||
9 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
10 | Eligibility Verification (REV) System or shall be submitted | ||||||
11 | directly to the Department of Human Services using required | ||||||
12 | admission forms. Effective September
1, 2014, admission | ||||||
13 | documents, including all prescreening
information, must be | ||||||
14 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
15 | to an accepted transaction shall be retained by a facility to | ||||||
16 | verify timely submittal. Once an admission transaction has | ||||||
17 | been completed, all resubmitted claims following prior | ||||||
18 | rejection are subject to receipt no later than 180 days after | ||||||
19 | the admission transaction has been completed. | ||||||
20 | Claims that are not submitted and received in compliance | ||||||
21 | with the foregoing requirements shall not be eligible for | ||||||
22 | payment under the medical assistance program, and the State | ||||||
23 | shall have no liability for payment of those claims. | ||||||
24 | To the extent consistent with applicable information and | ||||||
25 | privacy, security, and disclosure laws, State and federal | ||||||
26 | agencies and departments shall provide the Illinois Department |
| |||||||
| |||||||
1 | access to confidential and other information and data | ||||||
2 | necessary to perform eligibility and payment verifications and | ||||||
3 | other Illinois Department functions. This includes, but is not | ||||||
4 | limited to: information pertaining to licensure; | ||||||
5 | certification; earnings; immigration status; citizenship; wage | ||||||
6 | reporting; unearned and earned income; pension income; | ||||||
7 | employment; supplemental security income; social security | ||||||
8 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
9 | National Practitioner Data Bank (NPDB); program and agency | ||||||
10 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
11 | corporate information; and death records. | ||||||
12 | The Illinois Department shall enter into agreements with | ||||||
13 | State agencies and departments, and is authorized to enter | ||||||
14 | into agreements with federal agencies and departments, under | ||||||
15 | which such agencies and departments shall share data necessary | ||||||
16 | for medical assistance program integrity functions and | ||||||
17 | oversight. The Illinois Department shall develop, in | ||||||
18 | cooperation with other State departments and agencies, and in | ||||||
19 | compliance with applicable federal laws and regulations, | ||||||
20 | appropriate and effective methods to share such data. At a | ||||||
21 | minimum, and to the extent necessary to provide data sharing, | ||||||
22 | the Illinois Department shall enter into agreements with State | ||||||
23 | agencies and departments, and is authorized to enter into | ||||||
24 | agreements with federal agencies and departments, including , | ||||||
25 | but not limited to: the Secretary of State; the Department of | ||||||
26 | Revenue; the Department of Public Health; the Department of |
| |||||||
| |||||||
1 | Human Services; and the Department of Financial and | ||||||
2 | Professional Regulation. | ||||||
3 | Beginning in fiscal year 2013, the Illinois Department | ||||||
4 | shall set forth a request for information to identify the | ||||||
5 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
6 | claims system with the goals of streamlining claims processing | ||||||
7 | and provider reimbursement, reducing the number of pending or | ||||||
8 | rejected claims, and helping to ensure a more transparent | ||||||
9 | adjudication process through the utilization of: (i) provider | ||||||
10 | data verification and provider screening technology; and (ii) | ||||||
11 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
12 | post-adjudicated predictive modeling with an integrated case | ||||||
13 | management system with link analysis. Such a request for | ||||||
14 | information shall not be considered as a request for proposal | ||||||
15 | or as an obligation on the part of the Illinois Department to | ||||||
16 | take any action or acquire any products or services. | ||||||
17 | The Illinois Department shall establish policies, | ||||||
18 | procedures,
standards and criteria by rule for the | ||||||
19 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
20 | devices and durable medical equipment. Such
rules shall | ||||||
21 | provide, but not be limited to, the following services: (1)
| ||||||
22 | immediate repair or replacement of such devices by recipients; | ||||||
23 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
24 | medical equipment in a cost-effective manner, taking into
| ||||||
25 | consideration the recipient's medical prognosis, the extent of | ||||||
26 | the
recipient's needs, and the requirements and costs for |
| |||||||
| |||||||
1 | maintaining such
equipment. Subject to prior approval, such | ||||||
2 | rules shall enable a recipient to temporarily acquire and
use | ||||||
3 | alternative or substitute devices or equipment pending repairs | ||||||
4 | or
replacements of any device or equipment previously | ||||||
5 | authorized for such
recipient by the Department. | ||||||
6 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
7 | the Department may, by rule, exempt certain replacement | ||||||
8 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
9 | wheelchair parts, wheelchair accessories, and related seating | ||||||
10 | and positioning items, determine the wholesale price by | ||||||
11 | methods other than actual acquisition costs. | ||||||
12 | The Department shall require, by rule, all providers of | ||||||
13 | durable medical equipment to be accredited by an accreditation | ||||||
14 | organization approved by the federal Centers for Medicare and | ||||||
15 | Medicaid Services and recognized by the Department in order to | ||||||
16 | bill the Department for providing durable medical equipment to | ||||||
17 | recipients. No later than 15 months after the effective date | ||||||
18 | of the rule adopted pursuant to this paragraph, all providers | ||||||
19 | must meet the accreditation requirement.
| ||||||
20 | In order to promote environmental responsibility, meet the | ||||||
21 | needs of recipients and enrollees, and achieve significant | ||||||
22 | cost savings, the Department, or a managed care organization | ||||||
23 | under contract with the Department, may provide recipients or | ||||||
24 | managed care enrollees who have a prescription or Certificate | ||||||
25 | of Medical Necessity access to refurbished durable medical | ||||||
26 | equipment under this Section (excluding prosthetic and |
| |||||||
| |||||||
1 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
2 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
3 | products and associated services) through the State's | ||||||
4 | assistive technology program's reutilization program, using | ||||||
5 | staff with the Assistive Technology Professional (ATP) | ||||||
6 | Certification if the refurbished durable medical equipment: | ||||||
7 | (i) is available; (ii) is less expensive, including shipping | ||||||
8 | costs, than new durable medical equipment of the same type; | ||||||
9 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
10 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
11 | federal Food and Drug Administration regulations and guidance | ||||||
12 | governing the reprocessing of medical devices in health care | ||||||
13 | settings; and (v) equally meets the needs of the recipient or | ||||||
14 | enrollee. The reutilization program shall confirm that the | ||||||
15 | recipient or enrollee is not already in receipt of same or | ||||||
16 | similar equipment from another service provider, and that the | ||||||
17 | refurbished durable medical equipment equally meets the needs | ||||||
18 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
19 | be construed to limit recipient or enrollee choice to obtain | ||||||
20 | new durable medical equipment or place any additional prior | ||||||
21 | authorization conditions on enrollees of managed care | ||||||
22 | organizations. | ||||||
23 | The Department shall execute, relative to the nursing home | ||||||
24 | prescreening
project, written inter-agency agreements with the | ||||||
25 | Department of Human
Services and the Department on Aging, to | ||||||
26 | effect the following: (i) intake
procedures and common |
| |||||||
| |||||||
1 | eligibility criteria for those persons who are receiving
| ||||||
2 | non-institutional services; and (ii) the establishment and | ||||||
3 | development of
non-institutional services in areas of the | ||||||
4 | State where they are not currently
available or are | ||||||
5 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
6 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
7 | increase in the determination of need (DON) scores from 29 to | ||||||
8 | 37 for applicants for institutional and home and | ||||||
9 | community-based long term care; if and only if federal | ||||||
10 | approval is not granted, the Department may, in conjunction | ||||||
11 | with other affected agencies, implement utilization controls | ||||||
12 | or changes in benefit packages to effectuate a similar savings | ||||||
13 | amount for this population; and (iv) no later than July 1, | ||||||
14 | 2013, minimum level of care eligibility criteria for | ||||||
15 | institutional and home and community-based long term care; and | ||||||
16 | (v) no later than October 1, 2013, establish procedures to | ||||||
17 | permit long term care providers access to eligibility scores | ||||||
18 | for individuals with an admission date who are seeking or | ||||||
19 | receiving services from the long term care provider. In order | ||||||
20 | to select the minimum level of care eligibility criteria, the | ||||||
21 | Governor shall establish a workgroup that includes affected | ||||||
22 | agency representatives and stakeholders representing the | ||||||
23 | institutional and home and community-based long term care | ||||||
24 | interests. This Section shall not restrict the Department from | ||||||
25 | implementing lower level of care eligibility criteria for | ||||||
26 | community-based services in circumstances where federal |
| |||||||
| |||||||
1 | approval has been granted.
| ||||||
2 | The Illinois Department shall develop and operate, in | ||||||
3 | cooperation
with other State Departments and agencies and in | ||||||
4 | compliance with
applicable federal laws and regulations, | ||||||
5 | appropriate and effective
systems of health care evaluation | ||||||
6 | and programs for monitoring of
utilization of health care | ||||||
7 | services and facilities, as it affects
persons eligible for | ||||||
8 | medical assistance under this Code.
| ||||||
9 | The Illinois Department shall report annually to the | ||||||
10 | General Assembly,
no later than the second Friday in April of | ||||||
11 | 1979 and each year
thereafter, in regard to:
| ||||||
12 | (a) actual statistics and trends in utilization of | ||||||
13 | medical services by
public aid recipients;
| ||||||
14 | (b) actual statistics and trends in the provision of | ||||||
15 | the various medical
services by medical vendors;
| ||||||
16 | (c) current rate structures and proposed changes in | ||||||
17 | those rate structures
for the various medical vendors; and
| ||||||
18 | (d) efforts at utilization review and control by the | ||||||
19 | Illinois Department.
| ||||||
20 | The period covered by each report shall be the 3 years | ||||||
21 | ending on the June
30 prior to the report. The report shall | ||||||
22 | include suggested legislation
for consideration by the General | ||||||
23 | Assembly. The requirement for reporting to the General | ||||||
24 | Assembly shall be satisfied
by filing copies of the report as | ||||||
25 | required by Section 3.1 of the General Assembly Organization | ||||||
26 | Act, and filing such additional
copies
with the State |
| |||||||
| |||||||
1 | Government Report Distribution Center for the General
Assembly | ||||||
2 | as is required under paragraph (t) of Section 7 of the State
| ||||||
3 | Library Act.
| ||||||
4 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
5 | any, is conditioned on the rules being adopted in accordance | ||||||
6 | with all provisions of the Illinois Administrative Procedure | ||||||
7 | Act and all rules and procedures of the Joint Committee on | ||||||
8 | Administrative Rules; any purported rule not so adopted, for | ||||||
9 | whatever reason, is unauthorized. | ||||||
10 | On and after July 1, 2012, the Department shall reduce any | ||||||
11 | rate of reimbursement for services or other payments or alter | ||||||
12 | any methodologies authorized by this Code to reduce any rate | ||||||
13 | of reimbursement for services or other payments in accordance | ||||||
14 | with Section 5-5e. | ||||||
15 | Because kidney transplantation can be an appropriate, | ||||||
16 | cost-effective
alternative to renal dialysis when medically | ||||||
17 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
18 | of this Code, beginning October 1, 2014, the Department shall | ||||||
19 | cover kidney transplantation for noncitizens with end-stage | ||||||
20 | renal disease who are not eligible for comprehensive medical | ||||||
21 | benefits, who meet the residency requirements of Section 5-3 | ||||||
22 | of this Code, and who would otherwise meet the financial | ||||||
23 | requirements of the appropriate class of eligible persons | ||||||
24 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
25 | kidney transplantation, such person must be receiving | ||||||
26 | emergency renal dialysis services covered by the Department. |
| |||||||
| |||||||
1 | Providers under this Section shall be prior approved and | ||||||
2 | certified by the Department to perform kidney transplantation | ||||||
3 | and the services under this Section shall be limited to | ||||||
4 | services associated with kidney transplantation. | ||||||
5 | Notwithstanding any other provision of this Code to the | ||||||
6 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
7 | medication assisted treatment prescribed for the treatment of | ||||||
8 | alcohol dependence or treatment of opioid dependence shall be | ||||||
9 | covered under both fee for service and managed care medical | ||||||
10 | assistance programs for persons who are otherwise eligible for | ||||||
11 | medical assistance under this Article and shall not be subject | ||||||
12 | to any (1) utilization control, other than those established | ||||||
13 | under the American Society of Addiction Medicine patient | ||||||
14 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
15 | lifetime restriction limit
mandate. | ||||||
16 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
17 | for the treatment of an opioid overdose, including the | ||||||
18 | medication product, administration devices, and any pharmacy | ||||||
19 | fees related to the dispensing and administration of the | ||||||
20 | opioid antagonist, shall be covered under the medical | ||||||
21 | assistance program for persons who are otherwise eligible for | ||||||
22 | medical assistance under this Article. As used in this | ||||||
23 | Section, "opioid antagonist" means a drug that binds to opioid | ||||||
24 | receptors and blocks or inhibits the effect of opioids acting | ||||||
25 | on those receptors, including, but not limited to, naloxone | ||||||
26 | hydrochloride or any other similarly acting drug approved by |
| |||||||
| |||||||
1 | the U.S. Food and Drug Administration. | ||||||
2 | Upon federal approval, the Department shall provide | ||||||
3 | coverage and reimbursement for all drugs that are approved for | ||||||
4 | marketing by the federal Food and Drug Administration and that | ||||||
5 | are recommended by the federal Public Health Service or the | ||||||
6 | United States Centers for Disease Control and Prevention for | ||||||
7 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
8 | services, including, but not limited to, HIV and sexually | ||||||
9 | transmitted infection screening, treatment for sexually | ||||||
10 | transmitted infections, medical monitoring, assorted labs, and | ||||||
11 | counseling to reduce the likelihood of HIV infection among | ||||||
12 | individuals who are not infected with HIV but who are at high | ||||||
13 | risk of HIV infection. | ||||||
14 | A federally qualified health center, as defined in Section | ||||||
15 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
16 | reimbursed by the Department in accordance with the federally | ||||||
17 | qualified health center's encounter rate for services provided | ||||||
18 | to medical assistance recipients that are performed by a | ||||||
19 | dental hygienist, as defined under the Illinois Dental | ||||||
20 | Practice Act, working under the general supervision of a | ||||||
21 | dentist and employed by a federally qualified health center. | ||||||
22 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
23 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
24 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
25 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||||||
26 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. |
| |||||||
| |||||||
1 | 1-1-20; revised 9-18-19.)
| ||||||
2 | (305 ILCS 5/5-5f)
| ||||||
3 | Sec. 5-5f. Elimination and limitations of medical | ||||||
4 | assistance services. Notwithstanding any other provision of | ||||||
5 | this Code to the contrary, on and after July 1, 2012: | ||||||
6 | (a) The following service services shall no longer be | ||||||
7 | a covered service available under this Code: group | ||||||
8 | psychotherapy for residents of any facility licensed under | ||||||
9 | the Nursing Home Care Act or the Specialized Mental Health | ||||||
10 | Rehabilitation Act of 2013 ; and adult chiropractic | ||||||
11 | services . | ||||||
12 | (b) The Department shall place the following | ||||||
13 | limitations on services: (i) the Department shall limit | ||||||
14 | adult eyeglasses to one pair every 2 years; however, the | ||||||
15 | limitation does not apply to an individual who needs | ||||||
16 | different eyeglasses following a surgical procedure such | ||||||
17 | as cataract surgery; (ii) the Department shall set an | ||||||
18 | annual limit of a maximum of 20 visits for each of the | ||||||
19 | following services: adult speech, hearing, and language | ||||||
20 | therapy services, adult occupational therapy services, and | ||||||
21 | physical therapy services; on or after October 1, 2014, | ||||||
22 | the annual maximum limit of 20 visits shall expire but the | ||||||
23 | Department may require prior approval for all individuals | ||||||
24 | for speech, hearing, and language therapy services, | ||||||
25 | occupational therapy services, and physical therapy |
| |||||||
| |||||||
1 | services; (iii) the Department shall limit adult podiatry | ||||||
2 | services to individuals with diabetes; on or after October | ||||||
3 | 1, 2014, podiatry services shall not be limited to | ||||||
4 | individuals with diabetes; (iv) the Department shall pay | ||||||
5 | for caesarean sections at the normal vaginal delivery rate | ||||||
6 | unless a caesarean section was medically necessary; (v) | ||||||
7 | the Department shall limit adult dental services to | ||||||
8 | emergencies; beginning July 1, 2013, the Department shall | ||||||
9 | ensure that the following conditions are recognized as | ||||||
10 | emergencies: (A) dental services necessary for an | ||||||
11 | individual in order for the individual to be cleared for a | ||||||
12 | medical procedure, such as a transplant;
(B) extractions | ||||||
13 | and dentures necessary for a diabetic to receive proper | ||||||
14 | nutrition;
(C) extractions and dentures necessary as a | ||||||
15 | result of cancer treatment; and (D) dental services | ||||||
16 | necessary for the health of a pregnant woman prior to | ||||||
17 | delivery of her baby; on or after July 1, 2014, adult | ||||||
18 | dental services shall no longer be limited to emergencies, | ||||||
19 | and dental services necessary for the health of a pregnant | ||||||
20 | woman prior to delivery of her baby shall continue to be | ||||||
21 | covered; and (vi) effective July 1, 2012, the Department | ||||||
22 | shall place limitations and require concurrent review on | ||||||
23 | every inpatient detoxification stay to prevent repeat | ||||||
24 | admissions to any hospital for detoxification within 60 | ||||||
25 | days of a previous inpatient detoxification stay. The | ||||||
26 | Department shall convene a workgroup of hospitals, |
| |||||||
| |||||||
1 | substance abuse providers, care coordination entities, | ||||||
2 | managed care plans, and other stakeholders to develop | ||||||
3 | recommendations for quality standards, diversion to other | ||||||
4 | settings, and admission criteria for patients who need | ||||||
5 | inpatient detoxification, which shall be published on the | ||||||
6 | Department's website no later than September 1, 2013. | ||||||
7 | (c) The Department shall require prior approval of the | ||||||
8 | following services: wheelchair repairs costing more than | ||||||
9 | $400, coronary artery bypass graft, and bariatric surgery | ||||||
10 | consistent with Medicare standards concerning patient | ||||||
11 | responsibility. Wheelchair repair prior approval requests | ||||||
12 | shall be adjudicated within one business day of receipt of | ||||||
13 | complete supporting documentation. Providers may not break | ||||||
14 | wheelchair repairs into separate claims for purposes of | ||||||
15 | staying under the $400 threshold for requiring prior | ||||||
16 | approval. The wholesale price of manual and power | ||||||
17 | wheelchairs, durable medical equipment and supplies, and | ||||||
18 | complex rehabilitation technology products and services | ||||||
19 | shall be defined as actual acquisition cost including all | ||||||
20 | discounts. | ||||||
21 | (d) The Department shall establish benchmarks for | ||||||
22 | hospitals to measure and align payments to reduce | ||||||
23 | potentially preventable hospital readmissions, inpatient | ||||||
24 | complications, and unnecessary emergency room visits. In | ||||||
25 | doing so, the Department shall consider items, including, | ||||||
26 | but not limited to, historic and current acuity of care |
| |||||||
| |||||||
1 | and historic and current trends in readmission. The | ||||||
2 | Department shall publish provider-specific historical | ||||||
3 | readmission data and anticipated potentially preventable | ||||||
4 | targets 60 days prior to the start of the program. In the | ||||||
5 | instance of readmissions, the Department shall adopt | ||||||
6 | policies and rates of reimbursement for services and other | ||||||
7 | payments provided under this Code to ensure that, by June | ||||||
8 | 30, 2013, expenditures to hospitals are reduced by, at a | ||||||
9 | minimum, $40,000,000. | ||||||
10 | (e) The Department shall establish utilization | ||||||
11 | controls for the hospice program such that it shall not | ||||||
12 | pay for other care services when an individual is in | ||||||
13 | hospice. | ||||||
14 | (f) For home health services, the Department shall | ||||||
15 | require Medicare certification of providers participating | ||||||
16 | in the program and implement the Medicare face-to-face | ||||||
17 | encounter rule. The Department shall require providers to | ||||||
18 | implement auditable electronic service verification based | ||||||
19 | on global positioning systems or other cost-effective | ||||||
20 | technology. | ||||||
21 | (g) For the Home Services Program operated by the | ||||||
22 | Department of Human Services and the Community Care | ||||||
23 | Program operated by the Department on Aging, the | ||||||
24 | Department of Human Services, in cooperation with the | ||||||
25 | Department on Aging, shall implement an electronic service | ||||||
26 | verification based on global positioning systems or other |
| |||||||
| |||||||
1 | cost-effective technology. | ||||||
2 | (h) Effective with inpatient hospital admissions on or | ||||||
3 | after July 1, 2012, the Department shall reduce the | ||||||
4 | payment for a claim that indicates the occurrence of a | ||||||
5 | provider-preventable condition during the admission as | ||||||
6 | specified by the Department in rules. The Department shall | ||||||
7 | not pay for services related to an other | ||||||
8 | provider-preventable condition. | ||||||
9 | As used in this subsection (h): | ||||||
10 | "Provider-preventable condition" means a health care | ||||||
11 | acquired condition as defined under the federal Medicaid | ||||||
12 | regulation found at 42 CFR 447.26 or an other | ||||||
13 | provider-preventable condition. | ||||||
14 | "Other provider-preventable condition" means a wrong | ||||||
15 | surgical or other invasive procedure performed on a | ||||||
16 | patient, a surgical or other invasive procedure performed | ||||||
17 | on the wrong body part, or a surgical procedure or other | ||||||
18 | invasive procedure performed on the wrong patient. | ||||||
19 | (i) The Department shall implement cost savings | ||||||
20 | initiatives for advanced imaging services, cardiac imaging | ||||||
21 | services, pain management services, and back surgery. Such | ||||||
22 | initiatives shall be designed to achieve annual costs | ||||||
23 | savings.
| ||||||
24 | (j) The Department shall ensure that beneficiaries | ||||||
25 | with a diagnosis of epilepsy or seizure disorder in | ||||||
26 | Department records will not require prior approval for |
| |||||||
| |||||||
1 | anticonvulsants. | ||||||
2 | (Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
| ||||||
3 | Article 35. | ||||||
4 | Section 35-5. The Illinois Public Aid Code is amended by | ||||||
5 | changing Section 5-5 and by adding Section 5-42 as follows:
| ||||||
6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
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,
| ||||||
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 | ||||||
16 | home, or elsewhere; (6) medical care, or any
other type of | ||||||
17 | remedial care furnished by licensed practitioners; (7)
home | ||||||
18 | health care services; (8) private duty nursing service; (9) | ||||||
19 | clinic
services; (10) dental services, including prevention | ||||||
20 | and treatment of periodontal disease and dental caries disease | ||||||
21 | for pregnant women, provided by an individual licensed to | ||||||
22 | practice dentistry or dental surgery; for purposes of this | ||||||
23 | item (10), "dental services" means diagnostic, preventive, or |
| |||||||
| |||||||
1 | corrective procedures provided by or under the supervision of | ||||||
2 | a dentist in the practice of his or her profession; (11) | ||||||
3 | physical therapy and related
services; (12) prescribed drugs, | ||||||
4 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
5 | a physician skilled in the diseases of the eye,
or by an | ||||||
6 | optometrist, whichever the person may select; (13) other
| ||||||
7 | diagnostic, screening, preventive, and rehabilitative | ||||||
8 | services, including to ensure that the individual's need for | ||||||
9 | intervention or treatment of mental disorders or substance use | ||||||
10 | disorders or co-occurring mental health and substance use | ||||||
11 | disorders is determined using a uniform screening, assessment, | ||||||
12 | and 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)
| ||||||
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 | ||||||
22 | sexual 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 |
| |||||||
| |||||||
1 | laws of this State. The term "any other type of remedial care" | ||||||
2 | shall
include nursing care and nursing home service for | ||||||
3 | persons who rely on
treatment by spiritual means alone through | ||||||
4 | prayer for healing.
| ||||||
5 | Notwithstanding any other provision of this Section, a | ||||||
6 | comprehensive
tobacco use cessation program that includes | ||||||
7 | purchasing prescription drugs or
prescription medical devices | ||||||
8 | approved by the Food and Drug Administration shall
be covered | ||||||
9 | under the medical assistance
program under this Article for | ||||||
10 | persons who are otherwise eligible for
assistance under this | ||||||
11 | Article.
| ||||||
12 | Notwithstanding any other provision of this Section, all | ||||||
13 | tobacco cessation medications approved by the United States | ||||||
14 | Food and Drug Administration and all individual and group | ||||||
15 | tobacco cessation counseling services and telephone-based | ||||||
16 | counseling services and tobacco cessation medications provided | ||||||
17 | through the Illinois Tobacco Quitline shall be covered under | ||||||
18 | the medical assistance program for persons who are otherwise | ||||||
19 | eligible for assistance under this Article. The Department | ||||||
20 | shall comply with all federal requirements necessary to obtain | ||||||
21 | federal financial participation, as specified in 42 CFR | ||||||
22 | 433.15(b)(7), for telephone-based counseling services provided | ||||||
23 | through the Illinois Tobacco Quitline, including, but not | ||||||
24 | limited to: (i) entering into a memorandum of understanding or | ||||||
25 | interagency agreement with the Department of Public Health, as | ||||||
26 | administrator of the Illinois Tobacco Quitline; and (ii) |
| |||||||
| |||||||
1 | developing a cost allocation plan for Medicaid-allowable | ||||||
2 | Illinois Tobacco Quitline services in accordance with 45 CFR | ||||||
3 | 95.507. The Department shall submit the memorandum of | ||||||
4 | understanding or interagency agreement, the cost allocation | ||||||
5 | plan, and all other necessary documentation to the Centers for | ||||||
6 | Medicare and Medicaid Services for review and approval. | ||||||
7 | Coverage under this paragraph shall be contingent upon federal | ||||||
8 | approval. | ||||||
9 | Notwithstanding any other provision of this Code, | ||||||
10 | reproductive health care that is otherwise legal in Illinois | ||||||
11 | shall be covered under the medical assistance program for | ||||||
12 | persons who are otherwise eligible for medical assistance | ||||||
13 | under this Article. | ||||||
14 | Notwithstanding any other provision of this Code, the | ||||||
15 | Illinois
Department may not require, as a condition of payment | ||||||
16 | for any laboratory
test authorized under this Article, that a | ||||||
17 | physician's handwritten signature
appear on the laboratory | ||||||
18 | test order form. The Illinois Department may,
however, impose | ||||||
19 | other appropriate requirements regarding laboratory test
order | ||||||
20 | documentation.
| ||||||
21 | Upon receipt of federal approval of an amendment to the | ||||||
22 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
23 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
24 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
25 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
26 | that its vendor or vendors are enrolled as providers in the |
| |||||||
| |||||||
1 | medical assistance program and in any capitated Medicaid | ||||||
2 | managed care entity (MCE) serving individuals enrolled in a | ||||||
3 | school within the CPS system. Under any contract procured | ||||||
4 | under this provision, the vendor or vendors must serve only | ||||||
5 | individuals enrolled in a school within the CPS system. Claims | ||||||
6 | for services provided by CPS's vendor or vendors to recipients | ||||||
7 | of benefits in the medical assistance program under this Code, | ||||||
8 | the Children's Health Insurance Program, or the Covering ALL | ||||||
9 | KIDS Health Insurance Program shall be submitted to the | ||||||
10 | Department or the MCE in which the individual is enrolled for | ||||||
11 | payment and shall be reimbursed at the Department's or the | ||||||
12 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
13 | On and after July 1, 2012, the Department of Healthcare | ||||||
14 | and Family Services may provide the following services to
| ||||||
15 | persons
eligible for assistance under this Article who are | ||||||
16 | participating in
education, training or employment programs | ||||||
17 | operated by the Department of Human
Services as successor to | ||||||
18 | the Department of Public Aid:
| ||||||
19 | (1) dental services provided by or under the | ||||||
20 | supervision of a dentist; and
| ||||||
21 | (2) eyeglasses prescribed by a physician skilled in | ||||||
22 | the diseases of the
eye, or by an optometrist, whichever | ||||||
23 | the person may select.
| ||||||
24 | On and after July 1, 2018, the Department of Healthcare | ||||||
25 | and Family Services shall provide dental services to any adult | ||||||
26 | who is otherwise eligible for assistance under the medical |
| |||||||
| |||||||
1 | assistance program. As used in this paragraph, "dental | ||||||
2 | services" means diagnostic, preventative, restorative, or | ||||||
3 | corrective procedures, including procedures and services for | ||||||
4 | the prevention and treatment of periodontal disease and dental | ||||||
5 | caries disease, provided by an individual who is licensed to | ||||||
6 | practice dentistry or dental surgery or who is under the | ||||||
7 | supervision of a dentist in the practice of his or her | ||||||
8 | profession. | ||||||
9 | On and after July 1, 2018, targeted dental services, as | ||||||
10 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
11 | United States District Court for the Northern District of | ||||||
12 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
13 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
14 | the medical assistance program shall be established at no less | ||||||
15 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
16 | of the Consent Decree for targeted dental services that are | ||||||
17 | provided to persons under the age of 18 under the medical | ||||||
18 | assistance program. | ||||||
19 | Notwithstanding any other provision of this Code and | ||||||
20 | subject to federal approval, the Department may adopt rules to | ||||||
21 | allow a dentist who is volunteering his or her service at no | ||||||
22 | cost to render dental services through an enrolled | ||||||
23 | not-for-profit health clinic without the dentist personally | ||||||
24 | enrolling as a participating provider in the medical | ||||||
25 | assistance program. A not-for-profit health clinic shall | ||||||
26 | include a public health clinic or Federally Qualified Health |
| |||||||
| |||||||
1 | Center or other enrolled provider, as determined by the | ||||||
2 | Department, through which dental services covered under this | ||||||
3 | Section are performed. The Department shall establish a | ||||||
4 | process for payment of claims for reimbursement for covered | ||||||
5 | dental services rendered under this provision. | ||||||
6 | The Illinois Department, by rule, may distinguish and | ||||||
7 | classify the
medical services to be provided only in | ||||||
8 | accordance with the classes of
persons designated in Section | ||||||
9 | 5-2.
| ||||||
10 | The Department of Healthcare and Family Services must | ||||||
11 | provide coverage and reimbursement for amino acid-based | ||||||
12 | elemental formulas, regardless of delivery method, for the | ||||||
13 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
14 | short bowel syndrome when the prescribing physician has issued | ||||||
15 | a written order stating that the amino acid-based elemental | ||||||
16 | formula is medically necessary.
| ||||||
17 | The Illinois Department shall authorize the provision of, | ||||||
18 | and shall
authorize payment for, screening by low-dose | ||||||
19 | mammography for the presence of
occult breast cancer for women | ||||||
20 | 35 years of age or older who are eligible
for medical | ||||||
21 | assistance under this Article, as follows: | ||||||
22 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
23 | age.
| ||||||
24 | (B) An annual mammogram for women 40 years of age or | ||||||
25 | older. | ||||||
26 | (C) A mammogram at the age and intervals considered |
| |||||||
| |||||||
1 | medically necessary by the woman's health care provider | ||||||
2 | for women under 40 years of age and having a family history | ||||||
3 | of breast cancer, prior personal history of breast cancer, | ||||||
4 | positive genetic testing, or other risk factors. | ||||||
5 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
6 | entire breast or breasts if a mammogram demonstrates | ||||||
7 | heterogeneous or dense breast tissue or when medically | ||||||
8 | necessary as determined by a physician licensed to | ||||||
9 | practice medicine in all of its branches. | ||||||
10 | (E) A screening MRI when medically necessary, as | ||||||
11 | determined by a physician licensed to practice medicine in | ||||||
12 | all of its branches. | ||||||
13 | (F) A diagnostic mammogram when medically necessary, | ||||||
14 | as determined by a physician licensed to practice medicine | ||||||
15 | in all its branches, advanced practice registered nurse, | ||||||
16 | or physician assistant. | ||||||
17 | The Department shall not impose a deductible, coinsurance, | ||||||
18 | copayment, or any other cost-sharing requirement on the | ||||||
19 | coverage provided under this paragraph; except that this | ||||||
20 | sentence does not apply to coverage of diagnostic mammograms | ||||||
21 | to the extent such coverage would disqualify a high-deductible | ||||||
22 | health plan from eligibility for a health savings account | ||||||
23 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
24 | U.S.C. 223). | ||||||
25 | All screenings
shall
include a physical breast exam, | ||||||
26 | instruction on self-examination and
information regarding the |
| |||||||
| |||||||
1 | frequency of self-examination and its value as a
preventative | ||||||
2 | tool. | ||||||
3 | For purposes of this Section: | ||||||
4 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
5 | diagnostic mammography. | ||||||
6 | "Diagnostic
mammography" means a method of screening that | ||||||
7 | is designed to
evaluate an abnormality in a breast, including | ||||||
8 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
9 | subjective or objective
abnormality otherwise detected in the | ||||||
10 | breast. | ||||||
11 | "Low-dose mammography" means
the x-ray examination of the | ||||||
12 | breast using equipment dedicated specifically
for mammography, | ||||||
13 | including the x-ray tube, filter, compression device,
and | ||||||
14 | image receptor, with an average radiation exposure delivery
of | ||||||
15 | less than one rad per breast for 2 views of an average size | ||||||
16 | breast.
The term also includes digital mammography and | ||||||
17 | includes breast tomosynthesis. | ||||||
18 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
19 | involves the acquisition of projection images over the | ||||||
20 | stationary breast to produce cross-sectional digital | ||||||
21 | three-dimensional images of the breast. | ||||||
22 | If, at any time, the Secretary of the United States | ||||||
23 | Department of Health and Human Services, or its successor | ||||||
24 | agency, promulgates rules or regulations to be published in | ||||||
25 | the Federal Register or publishes a comment in the Federal | ||||||
26 | Register or issues an opinion, guidance, or other action that |
| |||||||
| |||||||
1 | would require the State, pursuant to any provision of the | ||||||
2 | Patient Protection and Affordable Care Act (Public Law | ||||||
3 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
4 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
5 | of any coverage for breast tomosynthesis outlined in this | ||||||
6 | paragraph, then the requirement that an insurer cover breast | ||||||
7 | tomosynthesis is inoperative other than any such coverage | ||||||
8 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
9 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
10 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
11 | this paragraph.
| ||||||
12 | On and after January 1, 2016, the Department shall ensure | ||||||
13 | that all networks of care for adult clients of the Department | ||||||
14 | include access to at least one breast imaging Center of | ||||||
15 | Imaging Excellence as certified by the American College of | ||||||
16 | Radiology. | ||||||
17 | On and after January 1, 2012, providers participating in a | ||||||
18 | quality improvement program approved by the Department shall | ||||||
19 | be reimbursed for screening and diagnostic mammography at the | ||||||
20 | same rate as the Medicare program's rates, including the | ||||||
21 | increased reimbursement for digital mammography. | ||||||
22 | The Department shall convene an expert panel including | ||||||
23 | representatives of hospitals, free-standing mammography | ||||||
24 | facilities, and doctors, including radiologists, to establish | ||||||
25 | quality standards for mammography. | ||||||
26 | On and after January 1, 2017, providers participating in a |
| |||||||
| |||||||
1 | breast cancer treatment quality improvement program approved | ||||||
2 | by the Department shall be reimbursed for breast cancer | ||||||
3 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
4 | program's rates for the data elements included in the breast | ||||||
5 | cancer treatment quality program. | ||||||
6 | The Department shall convene an expert panel, including | ||||||
7 | representatives of hospitals, free-standing breast cancer | ||||||
8 | treatment centers, breast cancer quality organizations, and | ||||||
9 | doctors, including breast surgeons, reconstructive breast | ||||||
10 | surgeons, oncologists, and primary care providers to establish | ||||||
11 | quality standards for breast cancer treatment. | ||||||
12 | Subject to federal approval, the Department shall | ||||||
13 | establish a rate methodology for mammography at federally | ||||||
14 | qualified health centers and other encounter-rate clinics. | ||||||
15 | These clinics or centers may also collaborate with other | ||||||
16 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
17 | Department shall report to the General Assembly on the status | ||||||
18 | of the provision set forth in this paragraph. | ||||||
19 | The Department shall establish a methodology to remind | ||||||
20 | women who are age-appropriate for screening mammography, but | ||||||
21 | who have not received a mammogram within the previous 18 | ||||||
22 | months, of the importance and benefit of screening | ||||||
23 | mammography. The Department shall work with experts in breast | ||||||
24 | cancer outreach and patient navigation to optimize these | ||||||
25 | reminders and shall establish a methodology for evaluating | ||||||
26 | their effectiveness and modifying the methodology based on the |
| |||||||
| |||||||
1 | evaluation. | ||||||
2 | The Department shall establish a performance goal for | ||||||
3 | primary care providers with respect to their female patients | ||||||
4 | over age 40 receiving an annual mammogram. This performance | ||||||
5 | goal shall be used to provide additional reimbursement in the | ||||||
6 | form of a quality performance bonus to primary care providers | ||||||
7 | who meet that goal. | ||||||
8 | The Department shall devise a means of case-managing or | ||||||
9 | patient navigation for beneficiaries diagnosed with breast | ||||||
10 | cancer. This program shall initially operate as a pilot | ||||||
11 | program in areas of the State with the highest incidence of | ||||||
12 | mortality related to breast cancer. At least one pilot program | ||||||
13 | site shall be in the metropolitan Chicago area and at least one | ||||||
14 | site shall be outside the metropolitan Chicago area. On or | ||||||
15 | after July 1, 2016, the pilot program shall be expanded to | ||||||
16 | include one site in western Illinois, one site in southern | ||||||
17 | Illinois, one site in central Illinois, and 4 sites within | ||||||
18 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
19 | be carried out measuring health outcomes and cost of care for | ||||||
20 | those served by the pilot program compared to similarly | ||||||
21 | situated patients who are not served by the pilot program. | ||||||
22 | The Department shall require all networks of care to | ||||||
23 | develop a means either internally or by contract with experts | ||||||
24 | in navigation and community outreach to navigate cancer | ||||||
25 | patients to comprehensive care in a timely fashion. The | ||||||
26 | Department shall require all networks of care to include |
| |||||||
| |||||||
1 | access for patients diagnosed with cancer to at least one | ||||||
2 | academic commission on cancer-accredited cancer program as an | ||||||
3 | in-network covered benefit. | ||||||
4 | Any medical or health care provider shall immediately | ||||||
5 | recommend, to
any pregnant woman who is being provided | ||||||
6 | prenatal services and is suspected
of having a substance use | ||||||
7 | disorder as defined in the Substance Use Disorder Act, | ||||||
8 | referral to a local substance use disorder treatment program | ||||||
9 | licensed by the Department of Human Services or to a licensed
| ||||||
10 | hospital which provides substance abuse treatment services. | ||||||
11 | The Department of Healthcare and Family Services
shall assure | ||||||
12 | coverage for the cost of treatment of the drug abuse or
| ||||||
13 | addiction for pregnant recipients in accordance with the | ||||||
14 | Illinois Medicaid
Program in conjunction with the Department | ||||||
15 | of Human Services.
| ||||||
16 | All medical providers providing medical assistance to | ||||||
17 | pregnant women
under this Code shall receive information from | ||||||
18 | the Department on the
availability of services under any
| ||||||
19 | program providing case management services for addicted women,
| ||||||
20 | including information on appropriate referrals for other | ||||||
21 | social services
that may be needed by addicted women in | ||||||
22 | addition to treatment for addiction.
| ||||||
23 | The Illinois Department, in cooperation with the | ||||||
24 | Departments of Human
Services (as successor to the Department | ||||||
25 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
26 | a public awareness campaign, may
provide information |
| |||||||
| |||||||
1 | concerning treatment for alcoholism and drug abuse and
| ||||||
2 | addiction, prenatal health care, and other pertinent programs | ||||||
3 | directed at
reducing the number of drug-affected infants born | ||||||
4 | to recipients of medical
assistance.
| ||||||
5 | Neither the Department of Healthcare and Family Services | ||||||
6 | nor the Department of Human
Services shall sanction the | ||||||
7 | recipient solely on the basis of
her substance abuse.
| ||||||
8 | The Illinois Department shall establish such regulations | ||||||
9 | governing
the dispensing of health services under this Article | ||||||
10 | as it shall deem
appropriate. The Department
should
seek the | ||||||
11 | advice of formal professional advisory committees appointed by
| ||||||
12 | the Director of the Illinois Department for the purpose of | ||||||
13 | providing regular
advice on policy and administrative matters, | ||||||
14 | information dissemination and
educational activities for | ||||||
15 | medical and health care providers, and
consistency in | ||||||
16 | procedures to the Illinois Department.
| ||||||
17 | The Illinois Department may develop and contract with | ||||||
18 | Partnerships of
medical providers to arrange medical services | ||||||
19 | for persons eligible under
Section 5-2 of this Code. | ||||||
20 | Implementation of this Section may be by
demonstration | ||||||
21 | projects in certain geographic areas. The Partnership shall
be | ||||||
22 | represented by a sponsor organization. The Department, by | ||||||
23 | rule, shall
develop qualifications for sponsors of | ||||||
24 | Partnerships. Nothing in this
Section shall be construed to | ||||||
25 | require that the sponsor organization be a
medical | ||||||
26 | organization.
|
| |||||||
| |||||||
1 | The sponsor must negotiate formal written contracts with | ||||||
2 | medical
providers for physician services, inpatient and | ||||||
3 | outpatient hospital care,
home health services, treatment for | ||||||
4 | alcoholism and substance abuse, and
other services determined | ||||||
5 | necessary by the Illinois Department by rule for
delivery by | ||||||
6 | Partnerships. Physician services must include prenatal and
| ||||||
7 | obstetrical care. The Illinois Department shall reimburse | ||||||
8 | medical services
delivered by Partnership providers to clients | ||||||
9 | in target areas according to
provisions of this Article and | ||||||
10 | the Illinois Health Finance Reform Act,
except that:
| ||||||
11 | (1) Physicians participating in a Partnership and | ||||||
12 | providing certain
services, which shall be determined by | ||||||
13 | the Illinois Department, to persons
in areas covered by | ||||||
14 | the Partnership may receive an additional surcharge
for | ||||||
15 | such services.
| ||||||
16 | (2) The Department may elect to consider and negotiate | ||||||
17 | financial
incentives to encourage the development of | ||||||
18 | Partnerships and the efficient
delivery of medical care.
| ||||||
19 | (3) Persons receiving medical services through | ||||||
20 | Partnerships may receive
medical and case management | ||||||
21 | services above the level usually offered
through the | ||||||
22 | medical assistance program.
| ||||||
23 | Medical providers shall be required to meet certain | ||||||
24 | qualifications to
participate in Partnerships to ensure the | ||||||
25 | delivery of high quality medical
services. These | ||||||
26 | qualifications shall be determined by rule of the Illinois
|
| |||||||
| |||||||
1 | Department and may be higher than qualifications for | ||||||
2 | participation in the
medical assistance program. Partnership | ||||||
3 | sponsors may prescribe reasonable
additional qualifications | ||||||
4 | for participation by medical providers, only with
the prior | ||||||
5 | written approval of the Illinois Department.
| ||||||
6 | Nothing in this Section shall limit the free choice of | ||||||
7 | practitioners,
hospitals, and other providers of medical | ||||||
8 | services by clients.
In order to ensure patient freedom of | ||||||
9 | choice, the Illinois Department shall
immediately promulgate | ||||||
10 | all rules and take all other necessary actions so that
| ||||||
11 | provided services may be accessed from therapeutically | ||||||
12 | certified optometrists
to the full extent of the Illinois | ||||||
13 | Optometric Practice Act of 1987 without
discriminating between | ||||||
14 | service providers.
| ||||||
15 | The Department shall apply for a waiver from the United | ||||||
16 | States Health
Care Financing Administration to allow for the | ||||||
17 | implementation of
Partnerships under this Section.
| ||||||
18 | The Illinois Department shall require health care | ||||||
19 | providers to maintain
records that document the medical care | ||||||
20 | and services provided to recipients
of Medical Assistance | ||||||
21 | under this Article. Such records must be retained for a period | ||||||
22 | of not less than 6 years from the date of service or as | ||||||
23 | provided by applicable State law, whichever period is longer, | ||||||
24 | except that if an audit is initiated within the required | ||||||
25 | retention period then the records must be retained until the | ||||||
26 | audit is completed and every exception is resolved. The |
| |||||||
| |||||||
1 | Illinois Department shall
require health care providers to | ||||||
2 | make available, when authorized by the
patient, in writing, | ||||||
3 | the medical records in a timely fashion to other
health care | ||||||
4 | providers who are treating or serving persons eligible for
| ||||||
5 | Medical Assistance under this Article. All dispensers of | ||||||
6 | medical services
shall be required to maintain and retain | ||||||
7 | business and professional records
sufficient to fully and | ||||||
8 | accurately document the nature, scope, details and
receipt of | ||||||
9 | the health care provided to persons eligible for medical
| ||||||
10 | assistance under this Code, in accordance with regulations | ||||||
11 | promulgated by
the Illinois Department. The rules and | ||||||
12 | regulations shall require that proof
of the receipt of | ||||||
13 | prescription drugs, dentures, prosthetic devices and
| ||||||
14 | eyeglasses by eligible persons under this Section accompany | ||||||
15 | each claim
for reimbursement submitted by the dispenser of | ||||||
16 | such medical services.
No such claims for reimbursement shall | ||||||
17 | be approved for payment by the Illinois
Department without | ||||||
18 | such proof of receipt, unless the Illinois Department
shall | ||||||
19 | have put into effect and shall be operating a system of | ||||||
20 | post-payment
audit and review which shall, on a sampling | ||||||
21 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
22 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
23 | for which payment is being made are actually being
received by | ||||||
24 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
25 | (the effective date of Public Act 83-1439), the Illinois | ||||||
26 | Department shall establish a
current list of acquisition costs |
| |||||||
| |||||||
1 | for all prosthetic devices and any
other items recognized as | ||||||
2 | medical equipment and supplies reimbursable under
this Article | ||||||
3 | and shall update such list on a quarterly basis, except that
| ||||||
4 | the acquisition costs of all prescription drugs shall be | ||||||
5 | updated no
less frequently than every 30 days as required by | ||||||
6 | Section 5-5.12.
| ||||||
7 | Notwithstanding any other law to the contrary, the | ||||||
8 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
9 | (the effective date of Public Act 98-104), establish | ||||||
10 | procedures to permit skilled care facilities licensed under | ||||||
11 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
12 | reimbursement purposes. Following development of these | ||||||
13 | procedures, the Department shall, by July 1, 2016, test the | ||||||
14 | viability of the new system and implement any necessary | ||||||
15 | operational or structural changes to its information | ||||||
16 | technology platforms in order to allow for the direct | ||||||
17 | acceptance and payment of nursing home claims. | ||||||
18 | Notwithstanding any other law to the contrary, the | ||||||
19 | Illinois Department shall, within 365 days after August 15, | ||||||
20 | 2014 (the effective date of Public Act 98-963), establish | ||||||
21 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
22 | Community Care Act and MC/DD facilities licensed under the | ||||||
23 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
24 | purposes. Following development of these procedures, the | ||||||
25 | Department shall have an additional 365 days to test the | ||||||
26 | viability of the new system and to ensure that any necessary |
| |||||||
| |||||||
1 | operational or structural changes to its information | ||||||
2 | technology platforms are 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.
| ||||||
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 | ||||||
19 | liens 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 | ||||||
22 | period of conditional enrollment, the Department may
terminate | ||||||
23 | the vendor's eligibility to participate in, or may disenroll | ||||||
24 | the 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 |
| |||||||
| |||||||
1 | process.
However, a disenrolled vendor may reapply without | ||||||
2 | penalty.
| ||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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, within 45 | ||||||
7 | calendar days of receipt by the facility of required | ||||||
8 | prescreening information, new admissions with associated | ||||||
9 | admission documents shall be submitted through the Medical | ||||||
10 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
11 | Eligibility Verification (REV) System or shall be submitted | ||||||
12 | directly to the Department of Human Services using required | ||||||
13 | admission forms. Effective September
1, 2014, admission | ||||||
14 | documents, including all prescreening
information, must be | ||||||
15 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
16 | to an accepted transaction shall be retained by a facility to | ||||||
17 | verify timely submittal. Once an admission transaction has | ||||||
18 | been completed, all resubmitted claims following prior | ||||||
19 | rejection are subject to receipt no later than 180 days after | ||||||
20 | the admission transaction has been completed. | ||||||
21 | Claims that are not submitted and received in compliance | ||||||
22 | with the foregoing requirements shall not be eligible for | ||||||
23 | payment under the medical assistance program, and the State | ||||||
24 | shall have no liability for payment of those claims. | ||||||
25 | To the extent consistent with applicable information and | ||||||
26 | privacy, security, and disclosure laws, State and federal |
| |||||||
| |||||||
1 | agencies and departments shall provide the Illinois Department | ||||||
2 | access to confidential and other information and data | ||||||
3 | necessary to perform eligibility and payment verifications and | ||||||
4 | other Illinois Department functions. This includes, but is not | ||||||
5 | limited to: information pertaining to licensure; | ||||||
6 | certification; earnings; immigration status; citizenship; wage | ||||||
7 | reporting; unearned and earned income; pension income; | ||||||
8 | employment; supplemental security income; social security | ||||||
9 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
10 | National Practitioner Data Bank (NPDB); program and agency | ||||||
11 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
12 | corporate information; and death records. | ||||||
13 | The Illinois Department shall enter into agreements with | ||||||
14 | State agencies and departments, and is authorized to enter | ||||||
15 | into agreements with federal agencies and departments, under | ||||||
16 | which such agencies and departments shall share data necessary | ||||||
17 | for medical assistance program integrity functions and | ||||||
18 | oversight. The Illinois Department shall develop, in | ||||||
19 | cooperation with other State departments and agencies, and in | ||||||
20 | compliance with applicable federal laws and regulations, | ||||||
21 | appropriate and effective methods to share such data. At a | ||||||
22 | minimum, and to the extent necessary to provide data sharing, | ||||||
23 | the Illinois Department shall enter into agreements with State | ||||||
24 | agencies and departments, and is authorized to enter into | ||||||
25 | agreements with federal agencies and departments, including , | ||||||
26 | but not limited to: the Secretary of State; the Department of |
| |||||||
| |||||||
1 | Revenue; the Department of Public Health; the Department of | ||||||
2 | Human Services; and the Department of Financial and | ||||||
3 | Professional Regulation. | ||||||
4 | Beginning in fiscal year 2013, the Illinois Department | ||||||
5 | shall set forth a request for information to identify the | ||||||
6 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
7 | claims system with the goals of streamlining claims processing | ||||||
8 | and provider reimbursement, reducing the number of pending or | ||||||
9 | rejected claims, and helping to ensure a more transparent | ||||||
10 | adjudication process through the utilization of: (i) provider | ||||||
11 | data verification and provider screening technology; and (ii) | ||||||
12 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
13 | post-adjudicated predictive modeling with an integrated case | ||||||
14 | management system with link analysis. Such a request for | ||||||
15 | information shall not be considered as a request for proposal | ||||||
16 | or as an obligation on the part of the Illinois Department to | ||||||
17 | take any action or acquire any products or services. | ||||||
18 | The Illinois Department shall establish policies, | ||||||
19 | procedures,
standards and criteria by rule for the | ||||||
20 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
21 | devices and durable medical equipment. Such
rules shall | ||||||
22 | provide, but not be limited to, the following services: (1)
| ||||||
23 | immediate repair or replacement of such devices by recipients; | ||||||
24 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
25 | medical equipment in a cost-effective manner, taking into
| ||||||
26 | consideration the recipient's medical prognosis, the extent of |
| |||||||
| |||||||
1 | the
recipient's needs, and the requirements and costs for | ||||||
2 | maintaining such
equipment. Subject to prior approval, such | ||||||
3 | rules shall enable a recipient to temporarily acquire and
use | ||||||
4 | alternative or substitute devices or equipment pending repairs | ||||||
5 | or
replacements of any device or equipment previously | ||||||
6 | authorized for such
recipient by the Department. | ||||||
7 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
8 | the Department may, by rule, exempt certain replacement | ||||||
9 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
10 | wheelchair parts, wheelchair accessories, and related seating | ||||||
11 | and positioning items, determine the wholesale price by | ||||||
12 | methods other than actual acquisition costs. | ||||||
13 | The Department shall require, by rule, all providers of | ||||||
14 | durable medical equipment to be accredited by an accreditation | ||||||
15 | organization approved by the federal Centers for Medicare and | ||||||
16 | Medicaid Services and recognized by the Department in order to | ||||||
17 | bill the Department for providing durable medical equipment to | ||||||
18 | recipients. No later than 15 months after the effective date | ||||||
19 | of the rule adopted pursuant to this paragraph, all providers | ||||||
20 | must meet the accreditation requirement.
| ||||||
21 | In order to promote environmental responsibility, meet the | ||||||
22 | needs of recipients and enrollees, and achieve significant | ||||||
23 | cost savings, the Department, or a managed care organization | ||||||
24 | under contract with the Department, may provide recipients or | ||||||
25 | managed care enrollees who have a prescription or Certificate | ||||||
26 | of Medical Necessity access to refurbished durable medical |
| |||||||
| |||||||
1 | equipment under this Section (excluding prosthetic and | ||||||
2 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
3 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
4 | products and associated services) through the State's | ||||||
5 | assistive technology program's reutilization program, using | ||||||
6 | staff with the Assistive Technology Professional (ATP) | ||||||
7 | Certification if the refurbished durable medical equipment: | ||||||
8 | (i) is available; (ii) is less expensive, including shipping | ||||||
9 | costs, than new durable medical equipment of the same type; | ||||||
10 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
11 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
12 | federal Food and Drug Administration regulations and guidance | ||||||
13 | governing the reprocessing of medical devices in health care | ||||||
14 | settings; and (v) equally meets the needs of the recipient or | ||||||
15 | enrollee. The reutilization program shall confirm that the | ||||||
16 | recipient or enrollee is not already in receipt of same or | ||||||
17 | similar equipment from another service provider, and that the | ||||||
18 | refurbished durable medical equipment equally meets the needs | ||||||
19 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
20 | be construed to limit recipient or enrollee choice to obtain | ||||||
21 | new durable medical equipment or place any additional prior | ||||||
22 | authorization conditions on enrollees of managed care | ||||||
23 | organizations. | ||||||
24 | The Department shall execute, relative to the nursing home | ||||||
25 | prescreening
project, written inter-agency agreements with the | ||||||
26 | Department of Human
Services and the Department on Aging, to |
| |||||||
| |||||||
1 | effect the following: (i) intake
procedures and common | ||||||
2 | eligibility criteria for those persons who are receiving
| ||||||
3 | non-institutional services; and (ii) the establishment and | ||||||
4 | development of
non-institutional services in areas of the | ||||||
5 | State where they are not currently
available or are | ||||||
6 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
7 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
8 | increase in the determination of need (DON) scores from 29 to | ||||||
9 | 37 for applicants for institutional and home and | ||||||
10 | community-based long term care; if and only if federal | ||||||
11 | approval is not granted, the Department may, in conjunction | ||||||
12 | with other affected agencies, implement utilization controls | ||||||
13 | or changes in benefit packages to effectuate a similar savings | ||||||
14 | amount for this population; and (iv) no later than July 1, | ||||||
15 | 2013, minimum level of care eligibility criteria for | ||||||
16 | institutional and home and community-based long term care; and | ||||||
17 | (v) no later than October 1, 2013, establish procedures to | ||||||
18 | permit long term care providers access to eligibility scores | ||||||
19 | for individuals with an admission date who are seeking or | ||||||
20 | receiving services from the long term care provider. In order | ||||||
21 | to select the minimum level of care eligibility criteria, the | ||||||
22 | Governor shall establish a workgroup that includes affected | ||||||
23 | agency representatives and stakeholders representing the | ||||||
24 | institutional and home and community-based long term care | ||||||
25 | interests. This Section shall not restrict the Department from | ||||||
26 | implementing lower level of care eligibility criteria for |
| |||||||
| |||||||
1 | community-based services in circumstances where federal | ||||||
2 | approval has been granted.
| ||||||
3 | The Illinois Department shall develop and operate, in | ||||||
4 | cooperation
with other State Departments and agencies and in | ||||||
5 | compliance with
applicable federal laws and regulations, | ||||||
6 | appropriate and effective
systems of health care evaluation | ||||||
7 | and programs for monitoring of
utilization of health care | ||||||
8 | services and facilities, as it affects
persons eligible for | ||||||
9 | medical assistance under this Code.
| ||||||
10 | The Illinois Department shall report annually to the | ||||||
11 | General Assembly,
no later than the second Friday in April of | ||||||
12 | 1979 and each year
thereafter, in regard to:
| ||||||
13 | (a) actual statistics and trends in utilization of | ||||||
14 | medical services by
public aid recipients;
| ||||||
15 | (b) actual statistics and trends in the provision of | ||||||
16 | the various medical
services by medical vendors;
| ||||||
17 | (c) current rate structures and proposed changes in | ||||||
18 | those rate structures
for the various medical vendors; and
| ||||||
19 | (d) efforts at utilization review and control by the | ||||||
20 | Illinois Department.
| ||||||
21 | The period covered by each report shall be the 3 years | ||||||
22 | ending on the June
30 prior to the report. The report shall | ||||||
23 | include suggested legislation
for consideration by the General | ||||||
24 | Assembly. The requirement for reporting to the General | ||||||
25 | Assembly shall be satisfied
by filing copies of the report as | ||||||
26 | required by Section 3.1 of the General Assembly Organization |
| |||||||
| |||||||
1 | Act, and filing such additional
copies
with the State | ||||||
2 | Government Report Distribution Center for the General
Assembly | ||||||
3 | as is required under paragraph (t) of Section 7 of the State
| ||||||
4 | Library Act.
| ||||||
5 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
6 | any, is conditioned on the rules being adopted in accordance | ||||||
7 | with all provisions of the Illinois Administrative Procedure | ||||||
8 | Act and all rules and procedures of the Joint Committee on | ||||||
9 | Administrative Rules; any purported rule not so adopted, for | ||||||
10 | whatever reason, is unauthorized. | ||||||
11 | On and after July 1, 2012, the Department shall reduce any | ||||||
12 | rate of reimbursement for services or other payments or alter | ||||||
13 | any methodologies authorized by this Code to reduce any rate | ||||||
14 | of reimbursement for services or other payments in accordance | ||||||
15 | with Section 5-5e. | ||||||
16 | Because kidney transplantation can be an appropriate, | ||||||
17 | cost-effective
alternative to renal dialysis when medically | ||||||
18 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
19 | of this Code, beginning October 1, 2014, the Department shall | ||||||
20 | cover kidney transplantation for noncitizens with end-stage | ||||||
21 | renal disease who are not eligible for comprehensive medical | ||||||
22 | benefits, who meet the residency requirements of Section 5-3 | ||||||
23 | of this Code, and who would otherwise meet the financial | ||||||
24 | requirements of the appropriate class of eligible persons | ||||||
25 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
26 | kidney transplantation, such person must be receiving |
| |||||||
| |||||||
1 | emergency renal dialysis services covered by the Department. | ||||||
2 | Providers under this Section shall be prior approved and | ||||||
3 | certified by the Department to perform kidney transplantation | ||||||
4 | and the services under this Section shall be limited to | ||||||
5 | services associated with kidney transplantation. | ||||||
6 | Notwithstanding any other provision of this Code to the | ||||||
7 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
8 | medication assisted treatment prescribed for the treatment of | ||||||
9 | alcohol dependence or treatment of opioid dependence shall be | ||||||
10 | covered under both fee for service and managed care medical | ||||||
11 | assistance programs for persons who are otherwise eligible for | ||||||
12 | medical assistance under this Article and shall not be subject | ||||||
13 | to any (1) utilization control, other than those established | ||||||
14 | under the American Society of Addiction Medicine patient | ||||||
15 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
16 | lifetime restriction limit
mandate. | ||||||
17 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
18 | for the treatment of an opioid overdose, including the | ||||||
19 | medication product, administration devices, and any pharmacy | ||||||
20 | fees related to the dispensing and administration of the | ||||||
21 | opioid antagonist, shall be covered under the medical | ||||||
22 | assistance program for persons who are otherwise eligible for | ||||||
23 | medical assistance under this Article. As used in this | ||||||
24 | Section, "opioid antagonist" means a drug that binds to opioid | ||||||
25 | receptors and blocks or inhibits the effect of opioids acting | ||||||
26 | on those receptors, including, but not limited to, naloxone |
| |||||||
| |||||||
1 | hydrochloride or any other similarly acting drug approved by | ||||||
2 | the U.S. Food and Drug Administration. | ||||||
3 | Upon federal approval, the Department shall provide | ||||||
4 | coverage and reimbursement for all drugs that are approved for | ||||||
5 | marketing by the federal Food and Drug Administration and that | ||||||
6 | are recommended by the federal Public Health Service or the | ||||||
7 | United States Centers for Disease Control and Prevention for | ||||||
8 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
9 | services, including, but not limited to, HIV and sexually | ||||||
10 | transmitted infection screening, treatment for sexually | ||||||
11 | transmitted infections, medical monitoring, assorted labs, and | ||||||
12 | counseling to reduce the likelihood of HIV infection among | ||||||
13 | individuals who are not infected with HIV but who are at high | ||||||
14 | risk of HIV infection. | ||||||
15 | A federally qualified health center, as defined in Section | ||||||
16 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
17 | reimbursed by the Department in accordance with the federally | ||||||
18 | qualified health center's encounter rate for services provided | ||||||
19 | to medical assistance recipients that are performed by a | ||||||
20 | dental hygienist, as defined under the Illinois Dental | ||||||
21 | Practice Act, working under the general supervision of a | ||||||
22 | dentist and employed by a federally qualified health center. | ||||||
23 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
24 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
25 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
26 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; |
| |||||||
| |||||||
1 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | ||||||
2 | 1-1-20; revised 9-18-19.)
| ||||||
3 | (305 ILCS 5/5-42 new) | ||||||
4 | Sec. 5-42. Tobacco cessation coverage; managed care. | ||||||
5 | Notwithstanding any other provision of this Article, a managed | ||||||
6 | care organization under contract with the Department to | ||||||
7 | provide services to recipients of medical assistance shall | ||||||
8 | provide coverage for all tobacco cessation medications | ||||||
9 | approved by the United States Food and Drug Administration, | ||||||
10 | all individual and group tobacco cessation counseling | ||||||
11 | services, and all telephone-based counseling services and | ||||||
12 | tobacco cessation medications provided through the Illinois | ||||||
13 | Tobacco Quitline. The Department may adopt any rules necessary | ||||||
14 | to implement this Section.
| ||||||
15 | Article 45. | ||||||
16 | Section 45-5. The Illinois Public Aid Code is amended by | ||||||
17 | changing Section 12-4.35 as follows:
| ||||||
18 | (305 ILCS 5/12-4.35)
| ||||||
19 | Sec. 12-4.35. Medical services for certain noncitizens.
| ||||||
20 | (a) Notwithstanding
Section 1-11 of this Code or Section | ||||||
21 | 20(a) of the Children's Health Insurance
Program Act, the | ||||||
22 | Department of Healthcare and Family Services may provide |
| |||||||
| |||||||
1 | medical services to
noncitizens who have not yet attained 19 | ||||||
2 | years of age and who are not eligible
for medical assistance | ||||||
3 | under Article V of this Code or under the Children's
Health | ||||||
4 | Insurance Program created by the Children's Health Insurance | ||||||
5 | Program Act
due to their not meeting the otherwise applicable | ||||||
6 | provisions of Section 1-11
of this Code or Section 20(a) of the | ||||||
7 | Children's Health Insurance Program Act.
The medical services | ||||||
8 | available, standards for eligibility, and other conditions
of | ||||||
9 | participation under this Section shall be established by rule | ||||||
10 | by the
Department; however, any such rule shall be at least as | ||||||
11 | restrictive as the
rules for medical assistance under Article | ||||||
12 | V of this Code or the Children's
Health Insurance Program | ||||||
13 | created by the Children's Health Insurance Program
Act.
| ||||||
14 | (a-5) Notwithstanding Section 1-11 of this Code, the | ||||||
15 | Department of Healthcare and Family Services may provide | ||||||
16 | medical assistance in accordance with Article V of this Code | ||||||
17 | to noncitizens over the age of 65 years of age who are not | ||||||
18 | eligible for medical assistance under Article V of this Code | ||||||
19 | due to their not meeting the otherwise applicable provisions | ||||||
20 | of Section 1-11 of this Code, whose income is at or below 100% | ||||||
21 | of the federal poverty level after deducting the costs of | ||||||
22 | medical or other remedial care, and who would otherwise meet | ||||||
23 | the eligibility requirements in Section 5-2 of this Code. The | ||||||
24 | medical services available, standards for eligibility, and | ||||||
25 | other conditions of participation under this Section shall be | ||||||
26 | established by rule by the Department; however, any such rule |
| |||||||
| |||||||
1 | shall be at least as restrictive as the rules for medical | ||||||
2 | assistance under Article V of this Code. | ||||||
3 | (a-10) Notwithstanding the provisions of Section 1-11, the | ||||||
4 | Department shall cover immunosuppressive drugs and related | ||||||
5 | services associated with post-kidney transplant management, | ||||||
6 | excluding long-term care costs, for noncitizens who: (i) are | ||||||
7 | not eligible for comprehensive medical benefits; (ii) meet the | ||||||
8 | residency requirements of Section 5-3; and (iii) would meet | ||||||
9 | the financial eligibility requirements of Section 5-2. | ||||||
10 | (b) The Department is authorized to take any action, | ||||||
11 | including without
limitation cessation or limitation of | ||||||
12 | enrollment, reduction of available medical services,
and | ||||||
13 | changing standards for eligibility, that is deemed necessary | ||||||
14 | by the
Department during a State fiscal year to assure that | ||||||
15 | payments under this
Section do not exceed available funds.
| ||||||
16 | (c) Continued enrollment of
individuals into the program | ||||||
17 | created under subsection (a) of this Section in any fiscal | ||||||
18 | year is
contingent upon continued enrollment of individuals | ||||||
19 | into the Children's Health
Insurance Program during that | ||||||
20 | fiscal year.
| ||||||
21 | (d) (Blank).
| ||||||
22 | (Source: P.A. 101-636, eff. 6-10-20.)
| ||||||
23 | Article 55. | ||||||
24 | Section 55-5. The Illinois Public Aid Code is amended by |
| |||||||
| |||||||
1 | changing Section 5-5 as follows:
| ||||||
2 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
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,
| ||||||
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 | ||||||
12 | home, or elsewhere; (6) medical care, or any
other type of | ||||||
13 | remedial care furnished by licensed practitioners; (7)
home | ||||||
14 | health care services; (8) private duty nursing service; (9) | ||||||
15 | clinic
services; (10) dental services, including prevention | ||||||
16 | and treatment of periodontal disease and dental caries disease | ||||||
17 | for pregnant women, provided by an individual licensed to | ||||||
18 | practice dentistry or dental surgery; for purposes of this | ||||||
19 | item (10), "dental services" means diagnostic, preventive, or | ||||||
20 | corrective procedures provided by or under the supervision of | ||||||
21 | a dentist in the practice of his or her profession; (11) | ||||||
22 | physical therapy and related
services; (12) prescribed drugs, | ||||||
23 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
24 | a physician skilled in the diseases of the eye,
or by an | ||||||
25 | optometrist, whichever the person may select; (13) other
|
| |||||||
| |||||||
1 | diagnostic, screening, preventive, and rehabilitative | ||||||
2 | services, including to ensure that the individual's need for | ||||||
3 | intervention or treatment of mental disorders or substance use | ||||||
4 | disorders or co-occurring mental health and substance use | ||||||
5 | disorders is determined using a uniform screening, assessment, | ||||||
6 | and evaluation process inclusive of criteria, for children and | ||||||
7 | adults; for purposes of this item (13), a uniform screening, | ||||||
8 | assessment, and evaluation process refers to a process that | ||||||
9 | includes an appropriate evaluation and, as warranted, a | ||||||
10 | referral; "uniform" does not mean the use of a singular | ||||||
11 | instrument, tool, or process that all must utilize; (14)
| ||||||
12 | transportation and such other expenses as may be necessary; | ||||||
13 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
14 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
15 | Treatment Act, for
injuries sustained as a result of the | ||||||
16 | sexual assault, including
examinations and laboratory tests to | ||||||
17 | discover evidence which may be used in
criminal proceedings | ||||||
18 | arising from the sexual assault; (16) the
diagnosis and | ||||||
19 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
20 | care, and any other type of remedial care recognized
under the | ||||||
21 | laws of this State. The term "any other type of remedial care" | ||||||
22 | shall
include nursing care and nursing home service for | ||||||
23 | persons who rely on
treatment by spiritual means alone through | ||||||
24 | prayer for healing.
| ||||||
25 | Notwithstanding any other provision of this Section, a | ||||||
26 | comprehensive
tobacco use cessation program that includes |
| |||||||
| |||||||
1 | purchasing prescription drugs or
prescription medical devices | ||||||
2 | approved by the Food and Drug Administration shall
be covered | ||||||
3 | under the medical assistance
program under this Article for | ||||||
4 | persons who are otherwise eligible for
assistance under this | ||||||
5 | Article.
| ||||||
6 | Notwithstanding any other provision of this Code, | ||||||
7 | reproductive health care that is otherwise legal in Illinois | ||||||
8 | shall be covered under the medical assistance program for | ||||||
9 | persons who are otherwise eligible for medical assistance | ||||||
10 | under this Article. | ||||||
11 | Notwithstanding any other provision of this Code, the | ||||||
12 | Illinois
Department may not require, as a condition of payment | ||||||
13 | for any laboratory
test authorized under this Article, that a | ||||||
14 | physician's handwritten signature
appear on the laboratory | ||||||
15 | test order form. The Illinois Department may,
however, impose | ||||||
16 | other appropriate requirements regarding laboratory test
order | ||||||
17 | documentation.
| ||||||
18 | Upon receipt of federal approval of an amendment to the | ||||||
19 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
20 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
21 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
22 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
23 | that its vendor or vendors are enrolled as providers in the | ||||||
24 | medical assistance program and in any capitated Medicaid | ||||||
25 | managed care entity (MCE) serving individuals enrolled in a | ||||||
26 | school within the CPS system. Under any contract procured |
| |||||||
| |||||||
1 | under this provision, the vendor or vendors must serve only | ||||||
2 | individuals enrolled in a school within the CPS system. Claims | ||||||
3 | for services provided by CPS's vendor or vendors to recipients | ||||||
4 | of benefits in the medical assistance program under this Code, | ||||||
5 | the Children's Health Insurance Program, or the Covering ALL | ||||||
6 | KIDS Health Insurance Program shall be submitted to the | ||||||
7 | Department or the MCE in which the individual is enrolled for | ||||||
8 | payment and shall be reimbursed at the Department's or the | ||||||
9 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
10 | On and after July 1, 2012, the Department of Healthcare | ||||||
11 | and Family Services may provide the following services to
| ||||||
12 | persons
eligible for assistance under this Article who are | ||||||
13 | participating in
education, training or employment programs | ||||||
14 | operated by the Department of Human
Services as successor to | ||||||
15 | the Department of Public Aid:
| ||||||
16 | (1) dental services provided by or under the | ||||||
17 | supervision of a dentist; and
| ||||||
18 | (2) eyeglasses prescribed by a physician skilled in | ||||||
19 | the diseases of the
eye, or by an optometrist, whichever | ||||||
20 | the person may select.
| ||||||
21 | On and after July 1, 2018, the Department of Healthcare | ||||||
22 | and Family Services shall provide dental services to any adult | ||||||
23 | who is otherwise eligible for assistance under the medical | ||||||
24 | assistance program. As used in this paragraph, "dental | ||||||
25 | services" means diagnostic, preventative, restorative, or | ||||||
26 | corrective procedures, including procedures and services for |
| |||||||
| |||||||
1 | the prevention and treatment of periodontal disease and dental | ||||||
2 | caries disease, provided by an individual who is licensed to | ||||||
3 | practice dentistry or dental surgery or who is under the | ||||||
4 | supervision of a dentist in the practice of his or her | ||||||
5 | profession. | ||||||
6 | On and after July 1, 2018, targeted dental services, as | ||||||
7 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
8 | United States District Court for the Northern District of | ||||||
9 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
10 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
11 | the medical assistance program shall be established at no less | ||||||
12 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
13 | of the Consent Decree for targeted dental services that are | ||||||
14 | provided to persons under the age of 18 under the medical | ||||||
15 | assistance program. | ||||||
16 | Notwithstanding any other provision of this Code and | ||||||
17 | subject to federal approval, the Department may adopt rules to | ||||||
18 | allow a dentist who is volunteering his or her service at no | ||||||
19 | cost to render dental services through an enrolled | ||||||
20 | not-for-profit health clinic without the dentist personally | ||||||
21 | enrolling as a participating provider in the medical | ||||||
22 | assistance program. A not-for-profit health clinic shall | ||||||
23 | include a public health clinic or Federally Qualified Health | ||||||
24 | Center or other enrolled provider, as determined by the | ||||||
25 | Department, through which dental services covered under this | ||||||
26 | Section are performed. The Department shall establish a |
| |||||||
| |||||||
1 | process for payment of claims for reimbursement for covered | ||||||
2 | dental services rendered under this provision. | ||||||
3 | The Illinois Department, by rule, may distinguish and | ||||||
4 | classify the
medical services to be provided only in | ||||||
5 | accordance with the classes of
persons designated in Section | ||||||
6 | 5-2.
| ||||||
7 | The Department of Healthcare and Family Services must | ||||||
8 | provide coverage and reimbursement for amino acid-based | ||||||
9 | elemental formulas, regardless of delivery method, for the | ||||||
10 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
11 | short bowel syndrome when the prescribing physician has issued | ||||||
12 | a written order stating that the amino acid-based elemental | ||||||
13 | formula is medically necessary.
| ||||||
14 | The Illinois Department shall authorize the provision of, | ||||||
15 | and shall
authorize payment for, screening by low-dose | ||||||
16 | mammography for the presence of
occult breast cancer for women | ||||||
17 | 35 years of age or older who are eligible
for medical | ||||||
18 | assistance under this Article, as follows: | ||||||
19 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
20 | age.
| ||||||
21 | (B) An annual mammogram for women 40 years of age or | ||||||
22 | older. | ||||||
23 | (C) A mammogram at the age and intervals considered | ||||||
24 | medically necessary by the woman's health care provider | ||||||
25 | for women under 40 years of age and having a family history | ||||||
26 | of breast cancer, prior personal history of breast cancer, |
| |||||||
| |||||||
1 | positive genetic testing, or other risk factors. | ||||||
2 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
3 | entire breast or breasts if a mammogram demonstrates | ||||||
4 | heterogeneous or dense breast tissue or when medically | ||||||
5 | necessary as determined by a physician licensed to | ||||||
6 | practice medicine in all of its branches. | ||||||
7 | (E) A screening MRI when medically necessary, as | ||||||
8 | determined by a physician licensed to practice medicine in | ||||||
9 | all of its branches. | ||||||
10 | (F) A diagnostic mammogram when medically necessary, | ||||||
11 | as determined by a physician licensed to practice medicine | ||||||
12 | in all its branches, advanced practice registered nurse, | ||||||
13 | or physician assistant. | ||||||
14 | The Department shall not impose a deductible, coinsurance, | ||||||
15 | copayment, or any other cost-sharing requirement on the | ||||||
16 | coverage provided under this paragraph; except that this | ||||||
17 | sentence does not apply to coverage of diagnostic mammograms | ||||||
18 | to the extent such coverage would disqualify a high-deductible | ||||||
19 | health plan from eligibility for a health savings account | ||||||
20 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
21 | U.S.C. 223). | ||||||
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. | ||||||
26 | For purposes of this Section: |
| |||||||
| |||||||
1 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
2 | diagnostic mammography. | ||||||
3 | "Diagnostic
mammography" means a method of screening that | ||||||
4 | is designed to
evaluate an abnormality in a breast, including | ||||||
5 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
6 | subjective or objective
abnormality otherwise detected in the | ||||||
7 | breast. | ||||||
8 | "Low-dose mammography" means
the x-ray examination of the | ||||||
9 | breast using equipment dedicated specifically
for mammography, | ||||||
10 | including the x-ray tube, filter, compression device,
and | ||||||
11 | image receptor, with an average radiation exposure delivery
of | ||||||
12 | less than one rad per breast for 2 views of an average size | ||||||
13 | breast.
The term also includes digital mammography and | ||||||
14 | includes breast tomosynthesis. | ||||||
15 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
16 | involves the acquisition of projection images over the | ||||||
17 | stationary breast to produce cross-sectional digital | ||||||
18 | three-dimensional images of the breast. | ||||||
19 | If, at any time, the Secretary of the United States | ||||||
20 | Department of Health and Human Services, or its successor | ||||||
21 | agency, promulgates rules or regulations to be published in | ||||||
22 | the Federal Register or publishes a comment in the Federal | ||||||
23 | Register or issues an opinion, guidance, or other action that | ||||||
24 | would require the State, pursuant to any provision of the | ||||||
25 | Patient Protection and Affordable Care Act (Public Law | ||||||
26 | 111-148), including, but not limited to, 42 U.S.C. |
| |||||||
| |||||||
1 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
2 | of any coverage for breast tomosynthesis outlined in this | ||||||
3 | paragraph, then the requirement that an insurer cover breast | ||||||
4 | tomosynthesis is inoperative other than any such coverage | ||||||
5 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
6 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
7 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
8 | this paragraph.
| ||||||
9 | On and after January 1, 2016, the Department shall ensure | ||||||
10 | that all networks of care for adult clients of the Department | ||||||
11 | include access to at least one breast imaging Center of | ||||||
12 | Imaging Excellence as certified by the American College of | ||||||
13 | Radiology. | ||||||
14 | On and after January 1, 2012, providers participating in a | ||||||
15 | quality improvement program approved by the Department shall | ||||||
16 | be reimbursed for screening and diagnostic mammography at the | ||||||
17 | same rate as the Medicare program's rates, including the | ||||||
18 | increased reimbursement for digital mammography. | ||||||
19 | The Department shall convene an expert panel including | ||||||
20 | representatives of hospitals, free-standing mammography | ||||||
21 | facilities, and doctors, including radiologists, to establish | ||||||
22 | quality standards for mammography. | ||||||
23 | On and after January 1, 2017, providers participating in a | ||||||
24 | breast cancer treatment quality improvement program approved | ||||||
25 | by the Department shall be reimbursed for breast cancer | ||||||
26 | treatment at a rate that is no lower than 95% of the Medicare |
| |||||||
| |||||||
1 | program's rates for the data elements included in the breast | ||||||
2 | cancer treatment quality program. | ||||||
3 | The Department shall convene an expert panel, including | ||||||
4 | representatives of hospitals, free-standing breast cancer | ||||||
5 | treatment centers, breast cancer quality organizations, and | ||||||
6 | doctors, including breast surgeons, reconstructive breast | ||||||
7 | surgeons, oncologists, and primary care providers to establish | ||||||
8 | quality standards for breast cancer treatment. | ||||||
9 | Subject to federal approval, the Department shall | ||||||
10 | establish a rate methodology for mammography at federally | ||||||
11 | qualified health centers and other encounter-rate clinics. | ||||||
12 | These clinics or centers may also collaborate with other | ||||||
13 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
14 | Department shall report to the General Assembly on the status | ||||||
15 | of the provision set forth in this paragraph. | ||||||
16 | The Department shall establish a methodology to remind | ||||||
17 | women who are age-appropriate for screening mammography, but | ||||||
18 | who have not received a mammogram within the previous 18 | ||||||
19 | months, of the importance and benefit of screening | ||||||
20 | mammography. The Department shall work with experts in breast | ||||||
21 | cancer outreach and patient navigation to optimize these | ||||||
22 | reminders and shall establish a methodology for evaluating | ||||||
23 | their effectiveness and modifying the methodology based on the | ||||||
24 | evaluation. | ||||||
25 | The Department shall establish a performance goal for | ||||||
26 | primary care providers with respect to their female patients |
| |||||||
| |||||||
1 | over age 40 receiving an annual mammogram. This performance | ||||||
2 | goal shall be used to provide additional reimbursement in the | ||||||
3 | form of a quality performance bonus to primary care providers | ||||||
4 | who meet that goal. | ||||||
5 | The Department shall devise a means of case-managing or | ||||||
6 | patient navigation for beneficiaries diagnosed with breast | ||||||
7 | cancer. This program shall initially operate as a pilot | ||||||
8 | program in areas of the State with the highest incidence of | ||||||
9 | mortality related to breast cancer. At least one pilot program | ||||||
10 | site shall be in the metropolitan Chicago area and at least one | ||||||
11 | site shall be outside the metropolitan Chicago area. On or | ||||||
12 | after July 1, 2016, the pilot program shall be expanded to | ||||||
13 | include one site in western Illinois, one site in southern | ||||||
14 | Illinois, one site in central Illinois, and 4 sites within | ||||||
15 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
16 | be carried out measuring health outcomes and cost of care for | ||||||
17 | those served by the pilot program compared to similarly | ||||||
18 | situated patients who are not served by the pilot program. | ||||||
19 | The Department shall require all networks of care to | ||||||
20 | develop a means either internally or by contract with experts | ||||||
21 | in navigation and community outreach to navigate cancer | ||||||
22 | patients to comprehensive care in a timely fashion. The | ||||||
23 | Department shall require all networks of care to include | ||||||
24 | access for patients diagnosed with cancer to at least one | ||||||
25 | academic commission on cancer-accredited cancer program as an | ||||||
26 | in-network covered benefit. |
| |||||||
| |||||||
1 | Any medical or health care provider shall immediately | ||||||
2 | recommend, to
any pregnant woman who is being provided | ||||||
3 | prenatal services and is suspected
of having a substance use | ||||||
4 | disorder as defined in the Substance Use Disorder Act, | ||||||
5 | referral to a local substance use disorder treatment program | ||||||
6 | licensed by the Department of Human Services or to a licensed
| ||||||
7 | hospital which provides substance abuse treatment services. | ||||||
8 | The Department of Healthcare and Family Services
shall assure | ||||||
9 | coverage for the cost of treatment of the drug abuse or
| ||||||
10 | addiction for pregnant recipients in accordance with the | ||||||
11 | Illinois Medicaid
Program in conjunction with the Department | ||||||
12 | of Human Services.
| ||||||
13 | All medical providers providing medical assistance to | ||||||
14 | pregnant women
under this Code shall receive information from | ||||||
15 | the Department on the
availability of services under any
| ||||||
16 | program providing case management services for addicted women,
| ||||||
17 | including information on appropriate referrals for other | ||||||
18 | social services
that may be needed by addicted women in | ||||||
19 | addition to treatment for addiction.
| ||||||
20 | The Illinois Department, in cooperation with the | ||||||
21 | Departments of Human
Services (as successor to the Department | ||||||
22 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
23 | a public awareness campaign, may
provide information | ||||||
24 | concerning treatment for alcoholism and drug abuse and
| ||||||
25 | addiction, prenatal health care, and other pertinent programs | ||||||
26 | directed at
reducing the number of drug-affected infants born |
| |||||||
| |||||||
1 | to recipients of medical
assistance.
| ||||||
2 | Neither the Department of Healthcare and Family Services | ||||||
3 | nor the Department of Human
Services shall sanction the | ||||||
4 | recipient solely on the basis of
her substance abuse.
| ||||||
5 | The Illinois Department shall establish such regulations | ||||||
6 | governing
the dispensing of health services under this Article | ||||||
7 | as it shall deem
appropriate. The Department
should
seek the | ||||||
8 | advice of formal professional advisory committees appointed by
| ||||||
9 | the Director of the Illinois Department for the purpose of | ||||||
10 | providing regular
advice on policy and administrative matters, | ||||||
11 | information dissemination and
educational activities for | ||||||
12 | medical and health care providers, and
consistency in | ||||||
13 | procedures to the Illinois Department.
| ||||||
14 | The Illinois Department may develop and contract with | ||||||
15 | Partnerships of
medical providers to arrange medical services | ||||||
16 | for persons eligible under
Section 5-2 of this Code. | ||||||
17 | Implementation of this Section may be by
demonstration | ||||||
18 | projects in certain geographic areas. The Partnership shall
be | ||||||
19 | represented by a sponsor organization. The Department, by | ||||||
20 | rule, shall
develop qualifications for sponsors of | ||||||
21 | Partnerships. Nothing in this
Section shall be construed to | ||||||
22 | require that the sponsor organization be a
medical | ||||||
23 | organization.
| ||||||
24 | The sponsor must negotiate formal written contracts with | ||||||
25 | medical
providers for physician services, inpatient and | ||||||
26 | outpatient hospital care,
home health services, treatment for |
| |||||||
| |||||||
1 | alcoholism and substance abuse, and
other services determined | ||||||
2 | necessary by the Illinois Department by rule for
delivery by | ||||||
3 | Partnerships. Physician services must include prenatal and
| ||||||
4 | obstetrical care. The Illinois Department shall reimburse | ||||||
5 | medical services
delivered by Partnership providers to clients | ||||||
6 | in target areas according to
provisions of this Article and | ||||||
7 | the Illinois Health Finance Reform Act,
except that:
| ||||||
8 | (1) Physicians participating in a Partnership and | ||||||
9 | providing certain
services, which shall be determined by | ||||||
10 | the Illinois Department, to persons
in areas covered by | ||||||
11 | the Partnership may receive an additional surcharge
for | ||||||
12 | such services.
| ||||||
13 | (2) The Department may elect to consider and negotiate | ||||||
14 | financial
incentives to encourage the development of | ||||||
15 | Partnerships and the efficient
delivery of medical care.
| ||||||
16 | (3) Persons receiving medical services through | ||||||
17 | Partnerships may receive
medical and case management | ||||||
18 | services above the level usually offered
through the | ||||||
19 | medical assistance program.
| ||||||
20 | Medical providers shall be required to meet certain | ||||||
21 | qualifications to
participate in Partnerships to ensure the | ||||||
22 | delivery of high quality medical
services. These | ||||||
23 | qualifications shall be determined by rule of the Illinois
| ||||||
24 | Department and may be higher than qualifications for | ||||||
25 | participation in the
medical assistance program. Partnership | ||||||
26 | sponsors may prescribe reasonable
additional qualifications |
| |||||||
| |||||||
1 | for participation by medical providers, only with
the prior | ||||||
2 | written approval of the Illinois Department.
| ||||||
3 | Nothing in this Section shall limit the free choice of | ||||||
4 | practitioners,
hospitals, and other providers of medical | ||||||
5 | services by clients.
In order to ensure patient freedom of | ||||||
6 | choice, the Illinois Department shall
immediately promulgate | ||||||
7 | all rules and take all other necessary actions so that
| ||||||
8 | provided services may be accessed from therapeutically | ||||||
9 | certified optometrists
to the full extent of the Illinois | ||||||
10 | Optometric Practice Act of 1987 without
discriminating between | ||||||
11 | service providers.
| ||||||
12 | The Department shall apply for a waiver from the United | ||||||
13 | States Health
Care Financing Administration to allow for the | ||||||
14 | implementation of
Partnerships under this Section.
| ||||||
15 | The Illinois Department shall require health care | ||||||
16 | providers to maintain
records that document the medical care | ||||||
17 | and services provided to recipients
of Medical Assistance | ||||||
18 | under this Article. Such records must be retained for a period | ||||||
19 | of not less than 6 years from the date of service or as | ||||||
20 | provided by applicable State law, whichever period is longer, | ||||||
21 | except that if an audit is initiated within the required | ||||||
22 | retention period then the records must be retained until the | ||||||
23 | audit is completed and every exception is resolved. The | ||||||
24 | Illinois Department shall
require health care providers to | ||||||
25 | make available, when authorized by the
patient, in writing, | ||||||
26 | the medical records in a timely fashion to other
health care |
| |||||||
| |||||||
1 | providers who are treating or serving persons eligible for
| ||||||
2 | Medical Assistance under this Article. All dispensers of | ||||||
3 | medical services
shall be required to maintain and retain | ||||||
4 | business and professional records
sufficient to fully and | ||||||
5 | accurately document the nature, scope, details and
receipt of | ||||||
6 | the health care provided to persons eligible for medical
| ||||||
7 | assistance under this Code, in accordance with regulations | ||||||
8 | promulgated by
the Illinois Department. The rules and | ||||||
9 | regulations shall require that proof
of the receipt of | ||||||
10 | 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 | ||||||
13 | such medical services.
No such claims for reimbursement shall | ||||||
14 | be approved for payment by the Illinois
Department without | ||||||
15 | such proof of receipt, unless the Illinois Department
shall | ||||||
16 | have put into effect and shall be operating a system of | ||||||
17 | post-payment
audit and review which shall, on a sampling | ||||||
18 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
19 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
20 | for which payment is being made are actually being
received by | ||||||
21 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
22 | (the effective date of Public Act 83-1439), the Illinois | ||||||
23 | Department shall establish a
current list of acquisition costs | ||||||
24 | for all prosthetic devices and any
other items recognized as | ||||||
25 | medical equipment and supplies reimbursable under
this Article | ||||||
26 | and shall update such list on a quarterly basis, except that
|
| |||||||
| |||||||
1 | the acquisition costs of all prescription drugs shall be | ||||||
2 | updated no
less frequently than every 30 days as required by | ||||||
3 | Section 5-5.12.
| ||||||
4 | Notwithstanding any other law to the contrary, the | ||||||
5 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
6 | (the effective date of Public Act 98-104), establish | ||||||
7 | procedures to permit skilled care facilities licensed under | ||||||
8 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
9 | reimbursement purposes. Following development of these | ||||||
10 | procedures, the Department shall, by July 1, 2016, test the | ||||||
11 | viability of the new system and implement any necessary | ||||||
12 | operational or structural changes to its information | ||||||
13 | technology platforms in order to allow for the direct | ||||||
14 | acceptance and payment of nursing home claims. | ||||||
15 | Notwithstanding any other law to the contrary, the | ||||||
16 | Illinois Department shall, within 365 days after August 15, | ||||||
17 | 2014 (the effective date of Public Act 98-963), establish | ||||||
18 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
19 | Community Care Act and MC/DD facilities licensed under the | ||||||
20 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
21 | purposes. Following development of these procedures, the | ||||||
22 | Department shall have an additional 365 days to test the | ||||||
23 | viability of the new system and to ensure that any necessary | ||||||
24 | operational or structural changes to its information | ||||||
25 | technology platforms are implemented. | ||||||
26 | The Illinois Department shall require all dispensers of |
| |||||||
| |||||||
1 | medical
services, other than an individual practitioner or | ||||||
2 | group of practitioners,
desiring to participate in the Medical | ||||||
3 | Assistance program
established under this Article to disclose | ||||||
4 | all financial, beneficial,
ownership, equity, surety or other | ||||||
5 | interests in any and all firms,
corporations, partnerships, | ||||||
6 | associations, business enterprises, joint
ventures, agencies, | ||||||
7 | institutions or other legal entities providing any
form of | ||||||
8 | health care services in this State under this Article.
| ||||||
9 | The Illinois Department may require that all dispensers of | ||||||
10 | medical
services desiring to participate in the medical | ||||||
11 | assistance program
established under this Article disclose, | ||||||
12 | under such terms and conditions as
the Illinois Department may | ||||||
13 | by rule establish, all inquiries from clients
and attorneys | ||||||
14 | regarding medical bills paid by the Illinois Department, which
| ||||||
15 | inquiries could indicate potential existence of claims or | ||||||
16 | liens for the
Illinois Department.
| ||||||
17 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
18 | period and shall be conditional for one year. During the | ||||||
19 | period of conditional enrollment, the Department may
terminate | ||||||
20 | the vendor's eligibility to participate in, or may disenroll | ||||||
21 | the vendor from, the medical assistance
program without cause. | ||||||
22 | Unless otherwise specified, such termination of eligibility or | ||||||
23 | disenrollment is not subject to the
Department's hearing | ||||||
24 | process.
However, a disenrolled vendor may reapply without | ||||||
25 | penalty.
| ||||||
26 | The Department has the discretion to limit the conditional |
| |||||||
| |||||||
1 | enrollment period for vendors based upon category of risk of | ||||||
2 | the vendor. | ||||||
3 | Prior to enrollment and during the conditional enrollment | ||||||
4 | period in the medical assistance program, all vendors shall be | ||||||
5 | subject to enhanced oversight, screening, and review based on | ||||||
6 | the risk of fraud, waste, and abuse that is posed by the | ||||||
7 | category of risk of the vendor. The Illinois Department shall | ||||||
8 | establish the procedures for oversight, screening, and review, | ||||||
9 | which may include, but need not be limited to: criminal and | ||||||
10 | financial background checks; fingerprinting; license, | ||||||
11 | certification, and authorization verifications; unscheduled or | ||||||
12 | unannounced site visits; database checks; prepayment audit | ||||||
13 | reviews; audits; payment caps; payment suspensions; and other | ||||||
14 | screening as required by federal or State law. | ||||||
15 | The Department shall define or specify the following: (i) | ||||||
16 | by provider notice, the "category of risk of the vendor" for | ||||||
17 | each type of vendor, which shall take into account the level of | ||||||
18 | screening applicable to a particular category of vendor under | ||||||
19 | federal law and regulations; (ii) by rule or provider notice, | ||||||
20 | the maximum length of the conditional enrollment period for | ||||||
21 | each category of risk of the vendor; and (iii) by rule, the | ||||||
22 | hearing rights, if any, afforded to a vendor in each category | ||||||
23 | of risk of the vendor that is terminated or disenrolled during | ||||||
24 | the conditional enrollment period. | ||||||
25 | To be eligible for payment consideration, a vendor's | ||||||
26 | payment claim or bill, either as an initial claim or as a |
| |||||||
| |||||||
1 | resubmitted claim following prior rejection, must be received | ||||||
2 | by the Illinois Department, or its fiscal intermediary, no | ||||||
3 | later than 180 days after the latest date on the claim on which | ||||||
4 | medical goods or services were provided, with the following | ||||||
5 | exceptions: | ||||||
6 | (1) In the case of a provider whose enrollment is in | ||||||
7 | process by the Illinois Department, the 180-day period | ||||||
8 | shall not begin until the date on the written notice from | ||||||
9 | the Illinois Department that the provider enrollment is | ||||||
10 | complete. | ||||||
11 | (2) In the case of errors attributable to the Illinois | ||||||
12 | Department or any of its claims processing intermediaries | ||||||
13 | which result in an inability to receive, process, or | ||||||
14 | adjudicate a claim, the 180-day period shall not begin | ||||||
15 | until the provider has been notified of the error. | ||||||
16 | (3) In the case of a provider for whom the Illinois | ||||||
17 | Department initiates the monthly billing process. | ||||||
18 | (4) In the case of a provider operated by a unit of | ||||||
19 | local government with a population exceeding 3,000,000 | ||||||
20 | when local government funds finance federal participation | ||||||
21 | for claims payments. | ||||||
22 | For claims for services rendered during a period for which | ||||||
23 | a recipient received retroactive eligibility, claims must be | ||||||
24 | filed within 180 days after the Department determines the | ||||||
25 | applicant is eligible. For claims for which the Illinois | ||||||
26 | Department is not the primary payer, claims must be submitted |
| |||||||
| |||||||
1 | to the Illinois Department within 180 days after the final | ||||||
2 | adjudication by the primary payer. | ||||||
3 | In the case of long term care facilities, within 45 | ||||||
4 | calendar days of receipt by the facility of required | ||||||
5 | prescreening information, new admissions with associated | ||||||
6 | admission documents shall be submitted through the Medical | ||||||
7 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
8 | Eligibility Verification (REV) System or shall be submitted | ||||||
9 | directly to the Department of Human Services using required | ||||||
10 | admission forms. Effective September
1, 2014, admission | ||||||
11 | documents, including all prescreening
information, must be | ||||||
12 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
13 | to an accepted transaction shall be retained by a facility to | ||||||
14 | verify timely submittal. Once an admission transaction has | ||||||
15 | been completed, all resubmitted claims following prior | ||||||
16 | rejection are subject to receipt no later than 180 days after | ||||||
17 | the admission transaction has been completed. | ||||||
18 | Claims that are not submitted and received in compliance | ||||||
19 | with the foregoing requirements shall not be eligible for | ||||||
20 | payment under the medical assistance program, and the State | ||||||
21 | shall have no liability for payment of those claims. | ||||||
22 | To the extent consistent with applicable information and | ||||||
23 | privacy, security, and disclosure laws, State and federal | ||||||
24 | agencies and departments shall provide the Illinois Department | ||||||
25 | access to confidential and other information and data | ||||||
26 | necessary to perform eligibility and payment verifications and |
| |||||||
| |||||||
1 | other Illinois Department functions. This includes, but is not | ||||||
2 | limited to: information pertaining to licensure; | ||||||
3 | certification; earnings; immigration status; citizenship; wage | ||||||
4 | reporting; unearned and earned income; pension income; | ||||||
5 | employment; supplemental security income; social security | ||||||
6 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
7 | National Practitioner Data Bank (NPDB); program and agency | ||||||
8 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
9 | corporate information; and death records. | ||||||
10 | The Illinois Department shall enter into agreements with | ||||||
11 | State agencies and departments, and is authorized to enter | ||||||
12 | into agreements with federal agencies and departments, under | ||||||
13 | which such agencies and departments shall share data necessary | ||||||
14 | for medical assistance program integrity functions and | ||||||
15 | oversight. The Illinois Department shall develop, in | ||||||
16 | cooperation with other State departments and agencies, and in | ||||||
17 | compliance with applicable federal laws and regulations, | ||||||
18 | appropriate and effective methods to share such data. At a | ||||||
19 | minimum, and to the extent necessary to provide data sharing, | ||||||
20 | the Illinois Department shall enter into agreements with State | ||||||
21 | agencies and departments, and is authorized to enter into | ||||||
22 | agreements with federal agencies and departments, including , | ||||||
23 | but not limited to: the Secretary of State; the Department of | ||||||
24 | Revenue; the Department of Public Health; the Department of | ||||||
25 | Human Services; and the Department of Financial and | ||||||
26 | Professional Regulation. |
| |||||||
| |||||||
1 | Beginning in fiscal year 2013, the Illinois Department | ||||||
2 | shall set forth a request for information to identify the | ||||||
3 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
4 | claims system with the goals of streamlining claims processing | ||||||
5 | and provider reimbursement, reducing the number of pending or | ||||||
6 | rejected claims, and helping to ensure a more transparent | ||||||
7 | adjudication process through the utilization of: (i) provider | ||||||
8 | data verification and provider screening technology; and (ii) | ||||||
9 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
10 | post-adjudicated predictive modeling with an integrated case | ||||||
11 | management system with link analysis. Such a request for | ||||||
12 | information shall not be considered as a request for proposal | ||||||
13 | or as an obligation on the part of the Illinois Department to | ||||||
14 | take any action or acquire any products or services. | ||||||
15 | The Illinois Department shall establish policies, | ||||||
16 | procedures,
standards and criteria by rule for the | ||||||
17 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
18 | devices and durable medical equipment. Such
rules shall | ||||||
19 | provide, but not be limited to, the following services: (1)
| ||||||
20 | immediate repair or replacement of such devices by recipients; | ||||||
21 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
22 | medical equipment in a cost-effective manner, taking into
| ||||||
23 | consideration the recipient's medical prognosis, the extent of | ||||||
24 | the
recipient's needs, and the requirements and costs for | ||||||
25 | maintaining such
equipment. Subject to prior approval, such | ||||||
26 | rules shall enable a recipient to temporarily acquire and
use |
| |||||||
| |||||||
1 | alternative or substitute devices or equipment pending repairs | ||||||
2 | or
replacements of any device or equipment previously | ||||||
3 | authorized for such
recipient by the Department. | ||||||
4 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
5 | the Department may, by rule, exempt certain replacement | ||||||
6 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
7 | wheelchair parts, wheelchair accessories, and related seating | ||||||
8 | and positioning items, determine the wholesale price by | ||||||
9 | methods other than actual acquisition costs. | ||||||
10 | The Department shall require, by rule, all providers of | ||||||
11 | durable medical equipment to be accredited by an accreditation | ||||||
12 | organization approved by the federal Centers for Medicare and | ||||||
13 | Medicaid Services and recognized by the Department in order to | ||||||
14 | bill the Department for providing durable medical equipment to | ||||||
15 | recipients. No later than 15 months after the effective date | ||||||
16 | of the rule adopted pursuant to this paragraph, all providers | ||||||
17 | must meet the accreditation requirement.
| ||||||
18 | In order to promote environmental responsibility, meet the | ||||||
19 | needs of recipients and enrollees, and achieve significant | ||||||
20 | cost savings, the Department, or a managed care organization | ||||||
21 | under contract with the Department, may provide recipients or | ||||||
22 | managed care enrollees who have a prescription or Certificate | ||||||
23 | of Medical Necessity access to refurbished durable medical | ||||||
24 | equipment under this Section (excluding prosthetic and | ||||||
25 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
26 | Pedorthics Practice Act and complex rehabilitation technology |
| |||||||
| |||||||
1 | products and associated services) through the State's | ||||||
2 | assistive technology program's reutilization program, using | ||||||
3 | staff with the Assistive Technology Professional (ATP) | ||||||
4 | Certification if the refurbished durable medical equipment: | ||||||
5 | (i) is available; (ii) is less expensive, including shipping | ||||||
6 | costs, than new durable medical equipment of the same type; | ||||||
7 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
8 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
9 | federal Food and Drug Administration regulations and guidance | ||||||
10 | governing the reprocessing of medical devices in health care | ||||||
11 | settings; and (v) equally meets the needs of the recipient or | ||||||
12 | enrollee. The reutilization program shall confirm that the | ||||||
13 | recipient or enrollee is not already in receipt of same or | ||||||
14 | similar equipment from another service provider, and that the | ||||||
15 | refurbished durable medical equipment equally meets the needs | ||||||
16 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
17 | be construed to limit recipient or enrollee choice to obtain | ||||||
18 | new durable medical equipment or place any additional prior | ||||||
19 | authorization conditions on enrollees of managed care | ||||||
20 | organizations. | ||||||
21 | The Department shall execute, relative to the nursing home | ||||||
22 | prescreening
project, written inter-agency agreements with the | ||||||
23 | Department of Human
Services and the Department on Aging, to | ||||||
24 | effect the following: (i) intake
procedures and common | ||||||
25 | eligibility criteria for those persons who are receiving
| ||||||
26 | non-institutional services; and (ii) the establishment and |
| |||||||
| |||||||
1 | development of
non-institutional services in areas of the | ||||||
2 | State where they are not currently
available or are | ||||||
3 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
4 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
5 | increase in the determination of need (DON) scores from 29 to | ||||||
6 | 37 for applicants for institutional and home and | ||||||
7 | community-based long term care; if and only if federal | ||||||
8 | approval is not granted, the Department may, in conjunction | ||||||
9 | with other affected agencies, implement utilization controls | ||||||
10 | or changes in benefit packages to effectuate a similar savings | ||||||
11 | amount for this population; and (iv) no later than July 1, | ||||||
12 | 2013, minimum level of care eligibility criteria for | ||||||
13 | institutional and home and community-based long term care; and | ||||||
14 | (v) no later than October 1, 2013, establish procedures to | ||||||
15 | permit long term care providers access to eligibility scores | ||||||
16 | for individuals with an admission date who are seeking or | ||||||
17 | receiving services from the long term care provider. In order | ||||||
18 | to select the minimum level of care eligibility criteria, the | ||||||
19 | Governor shall establish a workgroup that includes affected | ||||||
20 | agency representatives and stakeholders representing the | ||||||
21 | institutional and home and community-based long term care | ||||||
22 | interests. This Section shall not restrict the Department from | ||||||
23 | implementing lower level of care eligibility criteria for | ||||||
24 | community-based services in circumstances where federal | ||||||
25 | approval has been granted.
| ||||||
26 | The Illinois Department shall develop and operate, in |
| |||||||
| |||||||
1 | cooperation
with other State Departments and agencies and in | ||||||
2 | compliance with
applicable federal laws and regulations, | ||||||
3 | appropriate and effective
systems of health care evaluation | ||||||
4 | and programs for monitoring of
utilization of health care | ||||||
5 | services and facilities, as it affects
persons eligible for | ||||||
6 | medical assistance under this Code.
| ||||||
7 | The Illinois Department shall report annually to the | ||||||
8 | General Assembly,
no later than the second Friday in April of | ||||||
9 | 1979 and each year
thereafter, in regard to:
| ||||||
10 | (a) actual statistics and trends in utilization of | ||||||
11 | medical services by
public aid recipients;
| ||||||
12 | (b) actual statistics and trends in the provision of | ||||||
13 | the various medical
services by medical vendors;
| ||||||
14 | (c) current rate structures and proposed changes in | ||||||
15 | those rate structures
for the various medical vendors; and
| ||||||
16 | (d) efforts at utilization review and control by the | ||||||
17 | Illinois Department.
| ||||||
18 | The period covered by each report shall be the 3 years | ||||||
19 | ending on the June
30 prior to the report. The report shall | ||||||
20 | include suggested legislation
for consideration by the General | ||||||
21 | Assembly. The requirement for reporting to the General | ||||||
22 | Assembly shall be satisfied
by filing copies of the report as | ||||||
23 | required by Section 3.1 of the General Assembly Organization | ||||||
24 | Act, and filing such additional
copies
with the State | ||||||
25 | Government Report Distribution Center for the General
Assembly | ||||||
26 | as is required under paragraph (t) of Section 7 of the State
|
| |||||||
| |||||||
1 | Library Act.
| ||||||
2 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
3 | any, is conditioned on the rules being adopted in accordance | ||||||
4 | with all provisions of the Illinois Administrative Procedure | ||||||
5 | Act and all rules and procedures of the Joint Committee on | ||||||
6 | Administrative Rules; any purported rule not so adopted, for | ||||||
7 | whatever reason, is unauthorized. | ||||||
8 | On and after July 1, 2012, the Department shall reduce any | ||||||
9 | rate of reimbursement for services or other payments or alter | ||||||
10 | any methodologies authorized by this Code to reduce any rate | ||||||
11 | of reimbursement for services or other payments in accordance | ||||||
12 | with Section 5-5e. | ||||||
13 | Because kidney transplantation can be an appropriate, | ||||||
14 | cost-effective
alternative to renal dialysis when medically | ||||||
15 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
16 | of this Code, beginning October 1, 2014, the Department shall | ||||||
17 | cover kidney transplantation for noncitizens with end-stage | ||||||
18 | renal disease who are not eligible for comprehensive medical | ||||||
19 | benefits, who meet the residency requirements of Section 5-3 | ||||||
20 | of this Code, and who would otherwise meet the financial | ||||||
21 | requirements of the appropriate class of eligible persons | ||||||
22 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
23 | kidney transplantation, such person must be receiving | ||||||
24 | emergency renal dialysis services covered by the Department. | ||||||
25 | Providers under this Section shall be prior approved and | ||||||
26 | certified by the Department to perform kidney transplantation |
| |||||||
| |||||||
1 | and the services under this Section shall be limited to | ||||||
2 | services associated with kidney transplantation. | ||||||
3 | Notwithstanding any other provision of this Code to the | ||||||
4 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
5 | medication assisted treatment prescribed for the treatment of | ||||||
6 | alcohol dependence or treatment of opioid dependence shall be | ||||||
7 | covered under both fee for service and managed care medical | ||||||
8 | assistance programs for persons who are otherwise eligible for | ||||||
9 | medical assistance under this Article and shall not be subject | ||||||
10 | to any (1) utilization control, other than those established | ||||||
11 | under the American Society of Addiction Medicine patient | ||||||
12 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
13 | lifetime restriction limit
mandate. | ||||||
14 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
15 | for the treatment of an opioid overdose, including the | ||||||
16 | medication product, administration devices, and any pharmacy | ||||||
17 | fees related to the dispensing and administration of the | ||||||
18 | opioid antagonist, shall be covered under the medical | ||||||
19 | assistance program for persons who are otherwise eligible for | ||||||
20 | medical assistance under this Article. As used in this | ||||||
21 | Section, "opioid antagonist" means a drug that binds to opioid | ||||||
22 | receptors and blocks or inhibits the effect of opioids acting | ||||||
23 | on those receptors, including, but not limited to, naloxone | ||||||
24 | hydrochloride or any other similarly acting drug approved by | ||||||
25 | the U.S. Food and Drug Administration. | ||||||
26 | Upon federal approval, the Department shall provide |
| |||||||
| |||||||
1 | coverage and reimbursement for all drugs that are approved for | ||||||
2 | marketing by the federal Food and Drug Administration and that | ||||||
3 | are recommended by the federal Public Health Service or the | ||||||
4 | United States Centers for Disease Control and Prevention for | ||||||
5 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
6 | services, including, but not limited to, HIV and sexually | ||||||
7 | transmitted infection screening, treatment for sexually | ||||||
8 | transmitted infections, medical monitoring, assorted labs, and | ||||||
9 | counseling to reduce the likelihood of HIV infection among | ||||||
10 | individuals who are not infected with HIV but who are at high | ||||||
11 | risk of HIV infection. | ||||||
12 | A federally qualified health center, as defined in Section | ||||||
13 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
14 | reimbursed by the Department in accordance with the federally | ||||||
15 | qualified health center's encounter rate for services provided | ||||||
16 | to medical assistance recipients that are performed by a | ||||||
17 | dental hygienist, as defined under the Illinois Dental | ||||||
18 | Practice Act, working under the general supervision of a | ||||||
19 | dentist and employed by a federally qualified health center. | ||||||
20 | Subject to approval by the federal Centers for Medicare | ||||||
21 | and Medicaid Services of a Title XIX State Plan amendment | ||||||
22 | electing the Program of All-Inclusive Care for the Elderly | ||||||
23 | (PACE) as a State Medicaid option, as provided for by Subtitle | ||||||
24 | I (commencing with Section 4801) of Title IV of the Balanced | ||||||
25 | Budget Act of 1997 (Public Law 105-33) and Part 460 | ||||||
26 | (commencing with Section 460.2) of Subchapter E of Title 42 of |
| |||||||
| |||||||
1 | the Code of Federal Regulations, PACE program services shall | ||||||
2 | become a covered benefit of the medical assistance program, | ||||||
3 | subject to criteria established in accordance with all | ||||||
4 | applicable laws. | ||||||
5 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
6 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
7 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
8 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||||||
9 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | ||||||
10 | 1-1-20; revised 9-18-19.)
| ||||||
11 | Section 55-10. The All-Inclusive Care for the Elderly Act | ||||||
12 | is amended by changing Sections 1, 15 and 20 and by adding | ||||||
13 | Sections 6 and 16 as follows:
| ||||||
14 | (320 ILCS 40/1) (from Ch. 23, par. 6901)
| ||||||
15 | Sec. 1. Short title. This Act may be cited as the Program | ||||||
16 | of All-Inclusive Care for the Elderly Act.
| ||||||
17 | (Source: P.A. 87-411.)
| ||||||
18 | (320 ILCS 40/6 new) | ||||||
19 | Sec. 6. Definitions. As used in this Act: | ||||||
20 | "Department" means the Department of Healthcare and Family | ||||||
21 | Services. | ||||||
22 | "PACE organization" means an entity as defined in 42 CFR | ||||||
23 | 460.6.
|
| |||||||
| |||||||
1 | (320 ILCS 40/15) (from Ch. 23, par. 6915)
| ||||||
2 | Sec. 15. Program implementation.
| ||||||
3 | (a) The Department of Healthcare and Family Services must | ||||||
4 | prepare and submit a PACE State Plan amendment no later than | ||||||
5 | December 31, 2022 to the federal Centers for Medicare and | ||||||
6 | Medicaid Services to establish the Program of All-Inclusive | ||||||
7 | Care for the Elderly (PACE program) to provide | ||||||
8 | community-based, risk-based, and capitated long-term care | ||||||
9 | services as optional services under the Illinois Title XIX | ||||||
10 | State Plan and under contracts entered into between the | ||||||
11 | federal Centers for Medicare and Medicaid Services, the | ||||||
12 | Department of Healthcare and Family Services, and PACE | ||||||
13 | organizations, meeting the requirements of the Balanced Budget | ||||||
14 | Act of 1997 (Public Law 105-33) and any other applicable law or | ||||||
15 | regulation. Upon receipt of federal approval, the Illinois | ||||||
16 | Department of Public
Aid (now Department of Healthcare and | ||||||
17 | Family Services) shall implement the PACE program pursuant to | ||||||
18 | the provisions of the approved Title XIX State plan.
| ||||||
19 | (b) The Department of Healthcare and Family Services shall | ||||||
20 | facilitate the PACE organization application process no later | ||||||
21 | than
December 31, 2023. | ||||||
22 | (c) All PACE organizations selected shall begin operations | ||||||
23 | no later than June 30,
2024. | ||||||
24 | (d) (b) Using a risk-based financing model, the | ||||||
25 | organizations contracted to implement nonprofit organization |
| |||||||
| |||||||
1 | providing
the PACE program shall assume responsibility for all | ||||||
2 | costs generated by
the PACE program participants, and it shall | ||||||
3 | create and maintain a risk
reserve fund that will cover any | ||||||
4 | cost overages for any participant. The
PACE program is | ||||||
5 | responsible for the entire range of services in the
| ||||||
6 | consolidated service model, including hospital and nursing | ||||||
7 | home care,
according to participant need as determined by a | ||||||
8 | multidisciplinary team.
The contracted organizations are | ||||||
9 | nonprofit organization providing the PACE program is | ||||||
10 | responsible for
the full financial risk. Specific arrangements | ||||||
11 | of the risk-based
financing model shall be adopted and | ||||||
12 | negotiated by the federal Centers for Medicare and Medicaid | ||||||
13 | Services, the organizations contracted to implement nonprofit | ||||||
14 | organization providing the PACE
program, and the Department of | ||||||
15 | Healthcare and Family Services.
| ||||||
16 | (e) The requirements of the PACE model, as provided for | ||||||
17 | under Section 1894 (42 U.S.C. Sec. 1395eee) and Section 1934 | ||||||
18 | (42 U.S.C. Sec. 1396u-4) of the federal Social Security Act, | ||||||
19 | shall not be waived or modified. The requirements that shall | ||||||
20 | not be waived or modified include all of the following: | ||||||
21 | (1) The focus on frail elderly qualifying individuals | ||||||
22 | who require the level of care provided in a nursing | ||||||
23 | facility. | ||||||
24 | (2) The delivery of comprehensive, integrated acute | ||||||
25 | and long-term care services. | ||||||
26 | (3) The interdisciplinary team approach to care |
| |||||||
| |||||||
1 | management and service delivery. | ||||||
2 | (4) Capitated, integrated financing that allows the | ||||||
3 | provider to pool payments received from public and private | ||||||
4 | programs and individuals. | ||||||
5 | (5) The assumption by the provider of full financial | ||||||
6 | risk. | ||||||
7 | (6) The provision of a PACE benefit package for all | ||||||
8 | participants, regardless of source of payment, that shall | ||||||
9 | include all of the following: | ||||||
10 | (A) All Medicare-covered items and services. | ||||||
11 | (B) All Medicaid-covered items and services, as | ||||||
12 | specified in the Illinois Title XIX State Plan. | ||||||
13 | (C) Other services determined necessary by the | ||||||
14 | interdisciplinary team to improve and maintain the | ||||||
15 | participant's overall health status. | ||||||
16 | (f) The provisions under Sections 1-7 and 5-4 of the | ||||||
17 | Illinois Public Aid Code and under 80 Ill. Adm. Code 120.379, | ||||||
18 | 120.380, and 120.385 shall apply when determining the | ||||||
19 | eligibility for medical assistance of a person receiving PACE | ||||||
20 | services from an organization providing services under this | ||||||
21 | Act. | ||||||
22 | (g) Provisions governing the treatment of income and | ||||||
23 | resources of a married couple, for the purposes of determining | ||||||
24 | the eligibility of a nursing-facility certifiable or | ||||||
25 | institutionalized spouse, shall be established so as to | ||||||
26 | qualify for federal financial participation. |
| |||||||
| |||||||
1 | (h) Notwithstanding subsection (e), and only to the extent | ||||||
2 | federal financial participation is available, the Department | ||||||
3 | of Healthcare and Family Services, in consultation with PACE | ||||||
4 | organizations, may seek increased federal regulatory | ||||||
5 | flexibility from the federal Centers for Medicare and Medicaid | ||||||
6 | Services to modernize the PACE program, which may include, but | ||||||
7 | is not limited to, addressing all of the following: | ||||||
8 | (A) Composition of PACE interdisciplinary teams. | ||||||
9 | (B) Use of community-based physicians. | ||||||
10 | (C) Marketing practices. | ||||||
11 | (D) Development of a streamlined PACE waiver process. | ||||||
12 | This subsection shall be operative upon federal approval | ||||||
13 | of a capitation rate methodology as provided under Section 16. | ||||||
14 | (i) Each PACE organization shall provide the Department | ||||||
15 | with required reporting documents as set forth in 42 CFR | ||||||
16 | 460.190 through 42 CFR 460.196. | ||||||
17 | (Source: P.A. 94-48, eff. 7-1-05; 95-331, eff. 8-21-07.)
| ||||||
18 | (320 ILCS 40/16 new) | ||||||
19 | Sec. 16. Rates of payment. | ||||||
20 | (a) The General Assembly shall make appropriations to the | ||||||
21 | Department to fund services under this Act. The Department | ||||||
22 | shall develop and pay capitation rates to organizations | ||||||
23 | contracted to implement the PACE program as described in | ||||||
24 | Section 15 using actuarial methods. | ||||||
25 | The Department may develop capitation rates using a |
| |||||||
| |||||||
1 | standardized rate methodology across managed care plan models | ||||||
2 | for comparable populations. The specific rate methodology | ||||||
3 | applied to PACE organizations shall address features of PACE | ||||||
4 | that distinguishes it from other managed care plan models. | ||||||
5 | The rate methodology shall be consistent with actuarial | ||||||
6 | rate development principles and shall provide for all | ||||||
7 | reasonable, appropriate, and attainable costs for each PACE | ||||||
8 | organization within a region. | ||||||
9 | (b) The Department may develop statewide rates and apply | ||||||
10 | geographic adjustments, using available data sources deemed | ||||||
11 | appropriate by the Department. Consistent with actuarial | ||||||
12 | methods, the primary source of data used to develop rates for | ||||||
13 | each PACE organization shall be its cost and utilization data | ||||||
14 | for the Medical Assistance Program or other data sources as | ||||||
15 | deemed necessary by the Department. Rates developed under this | ||||||
16 | Section shall reflect the level of care associated with the | ||||||
17 | specific populations served under the contract. | ||||||
18 | (c) The rate methodology developed in accordance with this | ||||||
19 | Section shall contain a mechanism to account for the costs of | ||||||
20 | high-cost drugs and treatments. Rates developed shall be | ||||||
21 | actuarially certified prior to implementation. | ||||||
22 | (d) Consistent with the requirements of federal law, the | ||||||
23 | Department shall calculate an upper payment limit for payments | ||||||
24 | to PACE organizations. In calculating the upper payment limit, | ||||||
25 | the Department shall collect the applicable data as necessary | ||||||
26 | and shall consider the risk of nursing home placement for the |
| |||||||
| |||||||
1 | comparable population when estimating the level of care and | ||||||
2 | risk of PACE participants. | ||||||
3 | (e) The Department shall pay organizations contracted to | ||||||
4 | implement the PACE program at a rate within the certified | ||||||
5 | actuarially sound rate range developed with respect to that | ||||||
6 | entity as necessary to mitigate the impact to the entity of the | ||||||
7 | methodology developed in accordance with this Section. | ||||||
8 | (f) This Section shall apply for rates established no | ||||||
9 | earlier than July 1, 2022.
| ||||||
10 | (320 ILCS 40/20) (from Ch. 23, par. 6920)
| ||||||
11 | Sec. 20. Duties of the Department of Healthcare and Family | ||||||
12 | Services.
| ||||||
13 | (a) The Department of Healthcare and Family Services shall | ||||||
14 | provide a system for reimbursement for
services to the PACE | ||||||
15 | program.
| ||||||
16 | (b) The Department of Healthcare and Family Services shall | ||||||
17 | develop and implement contracts a contract with organizations | ||||||
18 | as provided in subsection (d) of Section 15 that set the
| ||||||
19 | nonprofit organization providing the PACE program that sets | ||||||
20 | forth
contractual obligations for the PACE program, including , | ||||||
21 | but not limited to ,
reporting and monitoring of utilization of | ||||||
22 | costs of the program as required
by the Illinois Department.
| ||||||
23 | (c) The Department of Healthcare and Family Services shall | ||||||
24 | acknowledge that it is participating
in the national PACE | ||||||
25 | project as initiated by Congress.
|
| |||||||
| |||||||
1 | (d) The Department of Healthcare and Family Services or | ||||||
2 | its designee shall be responsible for
certifying the | ||||||
3 | eligibility for services of all PACE program participants.
| ||||||
4 | (Source: P.A. 95-331, eff. 8-21-07.)
| ||||||
5 | (320 ILCS 40/30 rep.) | ||||||
6 | Section 55-15. The All-Inclusive Care for the Elderly Act | ||||||
7 | is amended by repealing Section 30.
| ||||||
8 | Article 65. | ||||||
9 | Section 65-5. The Illinois Public Aid Code is amended by | ||||||
10 | changing Section 5-19 as follows:
| ||||||
11 | (305 ILCS 5/5-19) (from Ch. 23, par. 5-19)
| ||||||
12 | Sec. 5-19. Healthy Kids Program.
| ||||||
13 | (a) Any child under the age of 21 eligible to receive | ||||||
14 | Medical Assistance
from the Illinois Department under Article | ||||||
15 | V of this Code shall be eligible
for Early and Periodic | ||||||
16 | Screening, Diagnosis and Treatment services provided
by the | ||||||
17 | Healthy Kids Program of the Illinois Department under the | ||||||
18 | Social
Security Act, 42 U.S.C. 1396d(r).
| ||||||
19 | (b) Enrollment of Children in Medicaid. The Illinois | ||||||
20 | Department shall
provide for receipt and initial processing of | ||||||
21 | applications for Medical
Assistance for all pregnant women and | ||||||
22 | children under the age of 21 at
locations in addition to those |
| |||||||
| |||||||
1 | used for processing applications for cash
assistance, | ||||||
2 | including disproportionate share hospitals, federally | ||||||
3 | qualified
health centers and other sites as selected by the | ||||||
4 | Illinois Department.
| ||||||
5 | (c) Healthy Kids Examinations. The Illinois Department | ||||||
6 | shall consider
any examination of a child eligible for the | ||||||
7 | Healthy Kids services provided
by a medical provider meeting | ||||||
8 | the requirements and complying with the rules
and regulations | ||||||
9 | of the Illinois Department to be reimbursed as a Healthy
Kids | ||||||
10 | examination.
| ||||||
11 | (d) Medical Screening Examinations.
| ||||||
12 | (1) The Illinois Department shall insure Medicaid | ||||||
13 | coverage for
periodic health, vision, hearing, and dental | ||||||
14 | screenings for children
eligible for Healthy Kids services | ||||||
15 | scheduled from a child's birth up until
the child turns 21 | ||||||
16 | years. The Illinois Department shall pay for vision,
| ||||||
17 | hearing, dental and health screening examinations for any | ||||||
18 | child eligible
for Healthy Kids services by qualified | ||||||
19 | providers at intervals established
by Department rules.
| ||||||
20 | (2) The Illinois Department shall pay for an | ||||||
21 | interperiodic health,
vision, hearing, or dental screening | ||||||
22 | examination for any child eligible
for Healthy Kids | ||||||
23 | services whenever an examination is:
| ||||||
24 | (A) requested by a child's parent, guardian, or
| ||||||
25 | custodian, or is determined to be necessary or | ||||||
26 | appropriate by social
services, developmental, health, |
| |||||||
| |||||||
1 | or educational personnel; or
| ||||||
2 | (B) necessary for enrollment in school; or
| ||||||
3 | (C) necessary for enrollment in a licensed day | ||||||
4 | care program,
including Head Start; or
| ||||||
5 | (D) necessary for placement in a licensed child | ||||||
6 | welfare facility,
including a foster home, group home | ||||||
7 | or child care institution; or
| ||||||
8 | (E) necessary for attendance at a camping program; | ||||||
9 | or
| ||||||
10 | (F) necessary for participation in an organized | ||||||
11 | athletic program; or
| ||||||
12 | (G) necessary for enrollment in an early childhood | ||||||
13 | education program
recognized by the Illinois State | ||||||
14 | Board of Education; or
| ||||||
15 | (H) necessary for participation in a Women, | ||||||
16 | Infant, and Children
(WIC) program; or
| ||||||
17 | (I) deemed appropriate by the Illinois Department.
| ||||||
18 | (e) Minimum Screening Protocols For Periodic Health | ||||||
19 | Screening
Examinations. Health Screening Examinations must | ||||||
20 | include the following
services:
| ||||||
21 | (1) Comprehensive Health and Development Assessment | ||||||
22 | including:
| ||||||
23 | (A) Development/Mental Health/Psychosocial | ||||||
24 | Assessment; and
| ||||||
25 | (B) Assessment of nutritional status including | ||||||
26 | tests for iron
deficiency and anemia for children at |
| |||||||
| |||||||
1 | the following ages: 9 months, 2
years, 8 years, and 18 | ||||||
2 | years;
| ||||||
3 | (2) Comprehensive unclothed physical exam;
| ||||||
4 | (3) Appropriate immunizations at a minimum, as | ||||||
5 | required by the
Secretary of the U.S. Department of Health | ||||||
6 | and Human Services under
42 U.S.C. 1396d(r).
| ||||||
7 | (4) Appropriate laboratory tests including blood lead | ||||||
8 | levels
appropriate for age and risk factors.
| ||||||
9 | (A) Anemia test.
| ||||||
10 | (B) Sickle cell test.
| ||||||
11 | (C) Tuberculin test at 12 months of age and every | ||||||
12 | 1-2 years
thereafter unless the treating health care | ||||||
13 | professional determines that
testing is medically | ||||||
14 | contraindicated.
| ||||||
15 | (D) Other -- The Illinois Department shall insure | ||||||
16 | that testing for
HIV, drug exposure, and sexually | ||||||
17 | transmitted diseases is provided for as
clinically | ||||||
18 | indicated.
| ||||||
19 | (5) Health Education. The Illinois Department shall | ||||||
20 | require providers
to provide anticipatory guidance as | ||||||
21 | recommended by the American Academy of
Pediatrics.
| ||||||
22 | (6) Vision Screening. The Illinois Department shall | ||||||
23 | require providers
to provide vision screenings consistent | ||||||
24 | with those set forth in the
Department of Public Health's | ||||||
25 | Administrative Rules.
| ||||||
26 | (7) Hearing Screening. The Illinois Department shall |
| |||||||
| |||||||
1 | require providers
to provide hearing screenings consistent | ||||||
2 | with those set forth in the
Department of Public Health's | ||||||
3 | Administrative Rules.
| ||||||
4 | (8) Dental Screening. The Illinois Department shall | ||||||
5 | require
providers to provide dental screenings consistent | ||||||
6 | with those set forth in the
Department of Public Health's | ||||||
7 | Administrative Rules.
| ||||||
8 | (f) Covered Medical Services. The Illinois Department | ||||||
9 | shall provide
coverage for all necessary health care, | ||||||
10 | diagnostic services, treatment and
other measures to correct | ||||||
11 | or ameliorate defects, physical and mental
illnesses, and | ||||||
12 | conditions whether discovered by the screening services or
not | ||||||
13 | for all children eligible for Medical Assistance under Article | ||||||
14 | V of
this Code.
| ||||||
15 | (g) Notice of Healthy Kids Services.
| ||||||
16 | (1) The Illinois Department shall inform any child | ||||||
17 | eligible for Healthy
Kids services and the child's family | ||||||
18 | about the benefits provided under the
Healthy Kids | ||||||
19 | Program, including, but not limited to, the following: | ||||||
20 | what
services are available under Healthy Kids, including | ||||||
21 | discussion of the
periodicity schedules and immunization | ||||||
22 | schedules, that services are
provided at no cost to | ||||||
23 | eligible children, the benefits of preventive health
care, | ||||||
24 | where the services are available, how to obtain them, and | ||||||
25 | that
necessary transportation and scheduling assistance is | ||||||
26 | available.
|
| |||||||
| |||||||
1 | (2) The Illinois Department shall widely disseminate | ||||||
2 | information
regarding the availability of the Healthy Kids | ||||||
3 | Program throughout the State
by outreach activities which | ||||||
4 | shall include, but not be limited to, (i) the
development | ||||||
5 | of cooperation agreements with local school districts, | ||||||
6 | public
health agencies, clinics, hospitals and other | ||||||
7 | health care providers,
including developmental disability | ||||||
8 | and mental health providers, and with
charities, to notify | ||||||
9 | the constituents of each of the Program and assist
| ||||||
10 | individuals, as feasible, with applying for the Program, | ||||||
11 | (ii) using the
media for public service announcements and | ||||||
12 | advertisements of the Program,
and (iii) developing | ||||||
13 | posters advertising the Program for display in
hospital | ||||||
14 | and clinic waiting rooms.
| ||||||
15 | (3) The Illinois Department shall utilize accepted | ||||||
16 | methods for
informing persons who are illiterate, blind, | ||||||
17 | deaf, or cannot understand the
English language, including | ||||||
18 | but not limited to public services announcements
and | ||||||
19 | advertisements in the foreign language media of radio, | ||||||
20 | television and
newspapers.
| ||||||
21 | (4) The Illinois Department shall provide notice of | ||||||
22 | the Healthy Kids
Program to every child eligible for | ||||||
23 | Healthy Kids services and his or her
family at the | ||||||
24 | following times:
| ||||||
25 | (A) orally by the intake worker and in writing at | ||||||
26 | the time of
application for Medical Assistance;
|
| |||||||
| |||||||
1 | (B) at the time the applicant is informed that he | ||||||
2 | or she is eligible
for Medical Assistance benefits; | ||||||
3 | and
| ||||||
4 | (C) at least 20 days before the date of any | ||||||
5 | periodic health, vision,
hearing, and dental | ||||||
6 | examination for any child eligible for Healthy Kids
| ||||||
7 | services. Notice given under this subparagraph (C) | ||||||
8 | must state that a
screening examination is due under | ||||||
9 | the periodicity schedules and must
advise the eligible | ||||||
10 | child and his or her family that the Illinois
| ||||||
11 | Department will provide assistance in scheduling an | ||||||
12 | appointment and
arranging medical transportation.
| ||||||
13 | (h) Data Collection. The Illinois Department shall collect | ||||||
14 | data in a
usable form to track utilization of Healthy Kids | ||||||
15 | screening examinations by
children eligible for Healthy Kids | ||||||
16 | services, including but not limited to
data showing screening | ||||||
17 | examinations and immunizations received, a summary
of | ||||||
18 | follow-up treatment received by children eligible for Healthy | ||||||
19 | Kids
services and the number of children receiving dental, | ||||||
20 | hearing and vision
services.
| ||||||
21 | (i) On and after July 1, 2012, the Department shall reduce | ||||||
22 | any rate of reimbursement for services or other payments or | ||||||
23 | alter any methodologies authorized by this Code to reduce any | ||||||
24 | rate of reimbursement for services or other payments in | ||||||
25 | accordance with Section 5-5e. | ||||||
26 | (j) To ensure full access to the benefits set forth in this
|
| |||||||
| |||||||
1 | Section, on and after January 1, 2022, the Illinois Department
| ||||||
2 | shall ensure that provider and hospital reimbursements for
| ||||||
3 | immunization as required under this Section are no lower than
| ||||||
4 | 70% of the median regional maximum administration fee for the | ||||||
5 | State of Illinois as established
by the U.S. Department of | ||||||
6 | Health and Human Services' Centers
for Medicare and Medicaid | ||||||
7 | Services. | ||||||
8 | (Source: P.A. 97-689, eff. 6-14-12.)
| ||||||
9 | Article 70. | ||||||
10 | Section 70-5. The Illinois Public Aid Code is amended by | ||||||
11 | changing Section 5-5.01a as follows:
| ||||||
12 | (305 ILCS 5/5-5.01a)
| ||||||
13 | Sec. 5-5.01a. Supportive living facilities program. | ||||||
14 | (a) The
Department shall establish and provide oversight | ||||||
15 | for a program of supportive living facilities that seek to | ||||||
16 | promote
resident independence, dignity, respect, and | ||||||
17 | well-being in the most
cost-effective manner.
| ||||||
18 | A supportive living facility is (i) a free-standing | ||||||
19 | facility or (ii) a distinct
physical and operational entity | ||||||
20 | within a mixed-use building that meets the criteria | ||||||
21 | established in subsection (d). A supportive
living facility | ||||||
22 | integrates housing with health, personal care, and supportive
| ||||||
23 | services and is a designated setting that offers residents |
| |||||||
| |||||||
1 | their own
separate, private, and distinct living units.
| ||||||
2 | Sites for the operation of the program
shall be selected | ||||||
3 | by the Department based upon criteria
that may include the | ||||||
4 | need for services in a geographic area, the
availability of | ||||||
5 | funding, and the site's ability to meet the standards.
| ||||||
6 | (b) Beginning July 1, 2014, subject to federal approval, | ||||||
7 | the Medicaid rates for supportive living facilities shall be | ||||||
8 | equal to the supportive living facility Medicaid rate | ||||||
9 | effective on June 30, 2014 increased by 8.85%.
Once the | ||||||
10 | assessment imposed at Article V-G of this Code is determined | ||||||
11 | to be a permissible tax under Title XIX of the Social Security | ||||||
12 | Act, the Department shall increase the Medicaid rates for | ||||||
13 | supportive living facilities effective on July 1, 2014 by | ||||||
14 | 9.09%. The Department shall apply this increase retroactively | ||||||
15 | to coincide with the imposition of the assessment in Article | ||||||
16 | V-G of this Code in accordance with the approval for federal | ||||||
17 | financial participation by the Centers for Medicare and | ||||||
18 | Medicaid Services. | ||||||
19 | The Medicaid rates for supportive living facilities | ||||||
20 | effective on July 1, 2017 must be equal to the rates in effect | ||||||
21 | for supportive living facilities on June 30, 2017 increased by | ||||||
22 | 2.8%. | ||||||
23 | Subject to federal approval, the Medicaid rates for | ||||||
24 | supportive living services on and after July 1, 2019 must be at | ||||||
25 | least 54.3% of the average total nursing facility services per | ||||||
26 | diem for the geographic areas defined by the Department while |
| |||||||
| |||||||
1 | maintaining the rate differential for dementia care and must | ||||||
2 | be updated whenever the total nursing facility service per | ||||||
3 | diems are updated. | ||||||
4 | (c) The Department may adopt rules to implement this | ||||||
5 | Section. Rules that
establish or modify the services, | ||||||
6 | standards, and conditions for participation
in the program | ||||||
7 | shall be adopted by the Department in consultation
with the | ||||||
8 | Department on Aging, the Department of Rehabilitation | ||||||
9 | Services, and
the Department of Mental Health and | ||||||
10 | Developmental Disabilities (or their
successor agencies).
| ||||||
11 | (d) Subject to federal approval by the Centers for | ||||||
12 | Medicare and Medicaid Services, the Department shall accept | ||||||
13 | for consideration of certification under the program any | ||||||
14 | application for a site or building where distinct parts of the | ||||||
15 | site or building are designated for purposes other than the | ||||||
16 | provision of supportive living services, but only if: | ||||||
17 | (1) those distinct parts of the site or building are | ||||||
18 | not designated for the purpose of providing assisted | ||||||
19 | living services as required under the Assisted Living and | ||||||
20 | Shared Housing Act; | ||||||
21 | (2) those distinct parts of the site or building are | ||||||
22 | completely separate from the part of the building used for | ||||||
23 | the provision of supportive living program services, | ||||||
24 | including separate entrances; | ||||||
25 | (3) those distinct parts of the site or building do | ||||||
26 | not share any common spaces with the part of the building |
| |||||||
| |||||||
1 | used for the provision of supportive living program | ||||||
2 | services; and | ||||||
3 | (4) those distinct parts of the site or building do | ||||||
4 | not share staffing with the part of the building used for | ||||||
5 | the provision of supportive living program services. | ||||||
6 | (e) Facilities or distinct parts of facilities which are | ||||||
7 | selected as supportive
living facilities and are in good | ||||||
8 | standing with the Department's rules are
exempt from the | ||||||
9 | provisions of the Nursing Home Care Act and the Illinois | ||||||
10 | Health
Facilities Planning Act.
| ||||||
11 | (f) Section 9817 of the American Rescue Plan Act of 2021 | ||||||
12 | (Public Law 117-2) authorizes a 10% enhanced federal medical | ||||||
13 | assistance percentage for supportive living services for a | ||||||
14 | 12-month period from April 1, 2021 through March 31, 2022. | ||||||
15 | Subject to federal approval, including the approval of any | ||||||
16 | necessary waiver amendments or other federally required | ||||||
17 | documents or assurances, for a 12-month period the Department | ||||||
18 | must pay a supplemental $26 per diem rate to all supportive | ||||||
19 | living facilities with the additional federal financial | ||||||
20 | participation funds that result from the enhanced federal | ||||||
21 | medical assistance percentage from April 1, 2021 through March | ||||||
22 | 31, 2022. The Department may issue parameters around how the | ||||||
23 | supplemental payment should be spent, including quality | ||||||
24 | improvement activities. The Department may alter the form, | ||||||
25 | methods, or timeframes concerning the supplemental per diem | ||||||
26 | rate to comply with any subsequent changes to federal law, |
| |||||||
| |||||||
1 | changes made by guidance issued by the federal Centers for | ||||||
2 | Medicare and Medicaid Services, or other changes necessary to | ||||||
3 | receive the enhanced federal medical assistance percentage. | ||||||
4 | (Source: P.A. 100-23, eff. 7-6-17; 100-583, eff. 4-6-18; | ||||||
5 | 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)
| ||||||
6 | Article 75. | ||||||
7 | Section 75-5. The Illinois Health Information Exchange and | ||||||
8 | Technology Act is amended by adding Section 997 as follows:
| ||||||
9 | (20 ILCS 3860/997 new) | ||||||
10 | Sec. 997. Repealer. This Act is repealed on January 1, | ||||||
11 | 2027.
| ||||||
12 | Article 80. | ||||||
13 | Section 80-5. The Illinois Public Aid Code is amended by | ||||||
14 | changing Section 5-5f as follows:
| ||||||
15 | (305 ILCS 5/5-5f)
| ||||||
16 | Sec. 5-5f. Elimination and limitations of medical | ||||||
17 | assistance services. Notwithstanding any other provision of | ||||||
18 | this Code to the contrary, on and after July 1, 2012: | ||||||
19 | (a) The following services shall no longer be a | ||||||
20 | covered service available under this Code: group |
| |||||||
| |||||||
1 | psychotherapy for residents of any facility licensed under | ||||||
2 | the Nursing Home Care Act or the Specialized Mental Health | ||||||
3 | Rehabilitation Act of 2013; and adult chiropractic | ||||||
4 | services. | ||||||
5 | (b) The Department shall place the following | ||||||
6 | limitations on services: (i) the Department shall limit | ||||||
7 | adult eyeglasses to one pair every 2 years; however, the | ||||||
8 | limitation does not apply to an individual who needs | ||||||
9 | different eyeglasses following a surgical procedure such | ||||||
10 | as cataract surgery; (ii) the Department shall set an | ||||||
11 | annual limit of a maximum of 20 visits for each of the | ||||||
12 | following services: adult speech, hearing, and language | ||||||
13 | therapy services, adult occupational therapy services, and | ||||||
14 | physical therapy services; on or after October 1, 2014, | ||||||
15 | the annual maximum limit of 20 visits shall expire but the | ||||||
16 | Department may require prior approval for all individuals | ||||||
17 | for speech, hearing, and language therapy services, | ||||||
18 | occupational therapy services, and physical therapy | ||||||
19 | services; (iii) the Department shall limit adult podiatry | ||||||
20 | services to individuals with diabetes; on or after October | ||||||
21 | 1, 2014, podiatry services shall not be limited to | ||||||
22 | individuals with diabetes; (iv) the Department shall pay | ||||||
23 | for caesarean sections at the normal vaginal delivery rate | ||||||
24 | unless a caesarean section was medically necessary; (v) | ||||||
25 | the Department shall limit adult dental services to | ||||||
26 | emergencies; beginning July 1, 2013, the Department shall |
| |||||||
| |||||||
1 | ensure that the following conditions are recognized as | ||||||
2 | emergencies: (A) dental services necessary for an | ||||||
3 | individual in order for the individual to be cleared for a | ||||||
4 | medical procedure, such as a transplant;
(B) extractions | ||||||
5 | and dentures necessary for a diabetic to receive proper | ||||||
6 | nutrition;
(C) extractions and dentures necessary as a | ||||||
7 | result of cancer treatment; and (D) dental services | ||||||
8 | necessary for the health of a pregnant woman prior to | ||||||
9 | delivery of her baby; on or after July 1, 2014, adult | ||||||
10 | dental services shall no longer be limited to emergencies, | ||||||
11 | and dental services necessary for the health of a pregnant | ||||||
12 | woman prior to delivery of her baby shall continue to be | ||||||
13 | covered; and (vi) effective July 1, 2012, the Department | ||||||
14 | shall place limitations and require concurrent review on | ||||||
15 | every inpatient detoxification stay to prevent repeat | ||||||
16 | admissions to any hospital for detoxification within 60 | ||||||
17 | days of a previous inpatient detoxification stay. The | ||||||
18 | Department shall convene a workgroup of hospitals, | ||||||
19 | substance abuse providers, care coordination entities, | ||||||
20 | managed care plans, and other stakeholders to develop | ||||||
21 | recommendations for quality standards, diversion to other | ||||||
22 | settings, and admission criteria for patients who need | ||||||
23 | inpatient detoxification, which shall be published on the | ||||||
24 | Department's website no later than September 1, 2013. | ||||||
25 | (c) The Department shall require prior approval of the | ||||||
26 | following services: wheelchair repairs costing more than |
| |||||||
| |||||||
1 | $750 $400 , coronary artery bypass graft, and bariatric | ||||||
2 | surgery consistent with Medicare standards concerning | ||||||
3 | patient responsibility. Wheelchair repair prior approval | ||||||
4 | requests shall be adjudicated within one business day of | ||||||
5 | receipt of complete supporting documentation. Providers | ||||||
6 | may not break wheelchair repairs into separate claims for | ||||||
7 | purposes of staying under the $750 $400 threshold for | ||||||
8 | requiring prior approval. The wholesale price of manual | ||||||
9 | and power wheelchairs, durable medical equipment and | ||||||
10 | supplies, and complex rehabilitation technology products | ||||||
11 | and services shall be defined as actual acquisition cost | ||||||
12 | including all discounts. | ||||||
13 | (d) The Department shall establish benchmarks for | ||||||
14 | hospitals to measure and align payments to reduce | ||||||
15 | potentially preventable hospital readmissions, inpatient | ||||||
16 | complications, and unnecessary emergency room visits. In | ||||||
17 | doing so, the Department shall consider items, including, | ||||||
18 | but not limited to, historic and current acuity of care | ||||||
19 | and historic and current trends in readmission. The | ||||||
20 | Department shall publish provider-specific historical | ||||||
21 | readmission data and anticipated potentially preventable | ||||||
22 | targets 60 days prior to the start of the program. In the | ||||||
23 | instance of readmissions, the Department shall adopt | ||||||
24 | policies and rates of reimbursement for services and other | ||||||
25 | payments provided under this Code to ensure that, by June | ||||||
26 | 30, 2013, expenditures to hospitals are reduced by, at a |
| |||||||
| |||||||
1 | minimum, $40,000,000. | ||||||
2 | (e) The Department shall establish utilization | ||||||
3 | controls for the hospice program such that it shall not | ||||||
4 | pay for other care services when an individual is in | ||||||
5 | hospice. | ||||||
6 | (f) For home health services, the Department shall | ||||||
7 | require Medicare certification of providers participating | ||||||
8 | in the program and implement the Medicare face-to-face | ||||||
9 | encounter rule. The Department shall require providers to | ||||||
10 | implement auditable electronic service verification based | ||||||
11 | on global positioning systems or other cost-effective | ||||||
12 | technology. | ||||||
13 | (g) For the Home Services Program operated by the | ||||||
14 | Department of Human Services and the Community Care | ||||||
15 | Program operated by the Department on Aging, the | ||||||
16 | Department of Human Services, in cooperation with the | ||||||
17 | Department on Aging, shall implement an electronic service | ||||||
18 | verification based on global positioning systems or other | ||||||
19 | cost-effective technology. | ||||||
20 | (h) Effective with inpatient hospital admissions on or | ||||||
21 | after July 1, 2012, the Department shall reduce the | ||||||
22 | payment for a claim that indicates the occurrence of a | ||||||
23 | provider-preventable condition during the admission as | ||||||
24 | specified by the Department in rules. The Department shall | ||||||
25 | not pay for services related to an other | ||||||
26 | provider-preventable condition. |
| |||||||
| |||||||
1 | As used in this subsection (h): | ||||||
2 | "Provider-preventable condition" means a health care | ||||||
3 | acquired condition as defined under the federal Medicaid | ||||||
4 | regulation found at 42 CFR 447.26 or an other | ||||||
5 | provider-preventable condition. | ||||||
6 | "Other provider-preventable condition" means a wrong | ||||||
7 | surgical or other invasive procedure performed on a | ||||||
8 | patient, a surgical or other invasive procedure performed | ||||||
9 | on the wrong body part, or a surgical procedure or other | ||||||
10 | invasive procedure performed on the wrong patient. | ||||||
11 | (i) The Department shall implement cost savings | ||||||
12 | initiatives for advanced imaging services, cardiac imaging | ||||||
13 | services, pain management services, and back surgery. Such | ||||||
14 | initiatives shall be designed to achieve annual costs | ||||||
15 | savings.
| ||||||
16 | (j) The Department shall ensure that beneficiaries | ||||||
17 | with a diagnosis of epilepsy or seizure disorder in | ||||||
18 | Department records will not require prior approval for | ||||||
19 | anticonvulsants. | ||||||
20 | (Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
| ||||||
21 | Article 85. | ||||||
22 | Section 85-5. The School Code is amended by changing | ||||||
23 | Section 14-15.01 as follows:
|
| |||||||
| |||||||
1 | (105 ILCS 5/14-15.01) (from Ch. 122, par. 14-15.01)
| ||||||
2 | Sec. 14-15.01. Community and Residential Services | ||||||
3 | Authority.
| ||||||
4 | (a) (1) The Community and Residential Services Authority | ||||||
5 | is
hereby created and shall consist of the following members:
| ||||||
6 | A representative of the State Board of Education;
| ||||||
7 | Four representatives of the Department of Human Services | ||||||
8 | appointed by the Secretary of Human Services,
with one member | ||||||
9 | from the Division of Community Health and
Prevention, one | ||||||
10 | member from the Division of Developmental Disabilities, one | ||||||
11 | member
from the Division of Mental Health, and one member from | ||||||
12 | the Division of
Rehabilitation Services;
| ||||||
13 | A representative of the Department of Children and Family | ||||||
14 | Services;
| ||||||
15 | A representative of the Department of Juvenile Justice;
| ||||||
16 | A representative of the Department of Healthcare and | ||||||
17 | Family Services;
| ||||||
18 | A representative of the Attorney General's Disability | ||||||
19 | Rights Advocacy
Division;
| ||||||
20 | The Chairperson and Minority Spokesperson of the House and | ||||||
21 | Senate
Committees on Elementary and Secondary Education or | ||||||
22 | their designees; and
| ||||||
23 | Six persons appointed by the Governor. Five of such
| ||||||
24 | appointees shall be experienced or knowledgeable relative to
| ||||||
25 | provision of services for individuals with a behavior
disorder
| ||||||
26 | or a severe emotional disturbance
and shall include |
| |||||||
| |||||||
1 | representatives of
both the private and public sectors, except | ||||||
2 | that no more than 2 of those 5
appointees may be from the | ||||||
3 | public sector and at least 2 must be or have been
directly | ||||||
4 | involved in provision of services to such individuals. The | ||||||
5 | remaining
member appointed by the Governor shall be or shall | ||||||
6 | have been a parent of an
individual with a
behavior disorder or | ||||||
7 | a severe emotional disturbance, and
that appointee may be from | ||||||
8 | either the private or the public sector.
| ||||||
9 | (2) Members appointed by the Governor shall be appointed | ||||||
10 | for terms
of 4 years and shall continue to serve until their | ||||||
11 | respective successors are
appointed; provided that the terms | ||||||
12 | of the original
appointees shall expire on August 1, 1990. Any | ||||||
13 | vacancy in the office of a
member appointed by the Governor | ||||||
14 | shall be filled by appointment of the
Governor for the | ||||||
15 | remainder of the term.
| ||||||
16 | A vacancy in the office of a member appointed by the | ||||||
17 | Governor exists when
one or more of the following events | ||||||
18 | occur:
| ||||||
19 | (i) An appointee dies;
| ||||||
20 | (ii) An appointee files a written resignation with the | ||||||
21 | Governor;
| ||||||
22 | (iii) An appointee ceases to be a legal resident of | ||||||
23 | the State of Illinois;
or
| ||||||
24 | (iv) An appointee fails to attend a majority of | ||||||
25 | regularly scheduled
Authority meetings in a fiscal year.
| ||||||
26 | Members who are representatives of an agency shall serve |
| |||||||
| |||||||
1 | at the will
of the agency head. Membership on the Authority | ||||||
2 | shall cease immediately
upon cessation of their affiliation | ||||||
3 | with the agency. If such a vacancy
occurs, the appropriate | ||||||
4 | agency head shall appoint another person to represent
the | ||||||
5 | agency.
| ||||||
6 | If a legislative member of the Authority ceases to be | ||||||
7 | Chairperson or
Minority Spokesperson of the designated | ||||||
8 | Committees, they shall
automatically be replaced on the | ||||||
9 | Authority by the person who assumes the
position of | ||||||
10 | Chairperson or Minority Spokesperson.
| ||||||
11 | (b) The Community and Residential Services Authority shall | ||||||
12 | have the
following powers and duties:
| ||||||
13 | (1) To conduct surveys to determine the extent of | ||||||
14 | need, the degree to
which documented need is currently | ||||||
15 | being met and feasible alternatives for
matching need with | ||||||
16 | resources.
| ||||||
17 | (2) To develop policy statements for interagency | ||||||
18 | cooperation to cover
all aspects of service delivery, | ||||||
19 | including laws, regulations and
procedures, and clear | ||||||
20 | guidelines for determining responsibility at all times.
| ||||||
21 | (3) To recommend policy statements
and provide | ||||||
22 | information regarding effective programs for delivery of
| ||||||
23 | services to all individuals under 22 years of age with a | ||||||
24 | behavior disorder
or a severe emotional disturbance in | ||||||
25 | public or private situations.
| ||||||
26 | (4) To review the criteria for service eligibility, |
| |||||||
| |||||||
1 | provision and
availability established by the governmental | ||||||
2 | agencies represented on this
Authority, and to recommend | ||||||
3 | changes, additions or deletions to such criteria.
| ||||||
4 | (5) To develop and submit to the Governor, the General | ||||||
5 | Assembly, the
Directors of the agencies represented on the | ||||||
6 | Authority, and the
State Board of Education a master plan | ||||||
7 | for individuals under 22 years of
age with a
behavior | ||||||
8 | disorder or a severe emotional disturbance,
including
| ||||||
9 | detailed plans of service ranging from the least to the | ||||||
10 | most
restrictive options; and to assist local communities, | ||||||
11 | upon request, in
developing
or strengthening collaborative | ||||||
12 | interagency networks.
| ||||||
13 | (6) To develop a process for making determinations in | ||||||
14 | situations where
there is a dispute relative to a plan of | ||||||
15 | service for
individuals or funding for a plan of service.
| ||||||
16 | (7) To provide technical assistance to parents, | ||||||
17 | service consumers,
providers, and member agency personnel | ||||||
18 | regarding statutory responsibilities
of human service and | ||||||
19 | educational agencies, and to provide such assistance
as | ||||||
20 | deemed necessary to appropriately access needed services.
| ||||||
21 | (8) To establish a pilot program to act as a | ||||||
22 | residential research hub to research and identify | ||||||
23 | appropriate residential settings for youth who are being | ||||||
24 | housed in an emergency room for more than 72 hours or who | ||||||
25 | are deemed beyond medical necessity in a psychiatric | ||||||
26 | hospital. If a child is deemed beyond medical necessity in |
| |||||||
| |||||||
1 | a psychiatric hospital and is in need of residential | ||||||
2 | placement, the goal of the program is to prevent a | ||||||
3 | lock-out pursuant to the goals of the Custody | ||||||
4 | Relinquishment Prevention Act. | ||||||
5 | (c) (1) The members of the Authority shall receive no | ||||||
6 | compensation for
their services but shall be entitled to | ||||||
7 | reimbursement of reasonable
expenses incurred while performing | ||||||
8 | their duties.
| ||||||
9 | (2) The Authority may appoint special study groups to | ||||||
10 | operate under
the direction of the Authority and persons | ||||||
11 | appointed to such groups shall
receive only reimbursement of | ||||||
12 | reasonable expenses incurred in the
performance of their | ||||||
13 | duties.
| ||||||
14 | (3) The Authority shall elect from its membership a | ||||||
15 | chairperson,
vice-chairperson and secretary.
| ||||||
16 | (4) The Authority may employ and fix the compensation of
| ||||||
17 | such employees and technical assistants as it deems necessary | ||||||
18 | to carry out
its powers and duties under this Act. Staff | ||||||
19 | assistance for the Authority
shall be provided by the State | ||||||
20 | Board of Education.
| ||||||
21 | (5) Funds for the ordinary and contingent expenses of the | ||||||
22 | Authority
shall be appropriated to the State Board of | ||||||
23 | Education in a separate line item.
| ||||||
24 | (d) (1) The Authority shall have power to promulgate rules | ||||||
25 | and
regulations to carry out its powers and duties under this | ||||||
26 | Act.
|
| |||||||
| |||||||
1 | (2) The Authority may accept monetary gifts or grants from | ||||||
2 | the federal
government or any agency thereof, from any | ||||||
3 | charitable foundation or
professional association or from any | ||||||
4 | other reputable source for
implementation of any program | ||||||
5 | necessary or desirable to the carrying out of
the general | ||||||
6 | purposes of the Authority. Such gifts and grants may be
held in | ||||||
7 | trust by the Authority and expended in the exercise of its | ||||||
8 | powers
and performance of its duties as prescribed by law.
| ||||||
9 | (3) The Authority shall submit an annual report of its | ||||||
10 | activities and
expenditures to the Governor, the General | ||||||
11 | Assembly, the
directors of agencies represented on the | ||||||
12 | Authority, and the State
Superintendent of Education.
| ||||||
13 | (e) The Executive Director of the Authority or his or her | ||||||
14 | designee shall be added as a participant on the Interagency | ||||||
15 | Clinical Team established in the intergovernmental agreement | ||||||
16 | among the Department of Healthcare and Family Services, the | ||||||
17 | Department of Children and Family Services, the Department of | ||||||
18 | Human Services, the State Board of Education, the Department | ||||||
19 | of Juvenile Justice, and the Department of Public Health, with | ||||||
20 | consent of the youth or the youth's guardian or family | ||||||
21 | pursuant to the Custody Relinquishment Prevention Act. | ||||||
22 | (Source: P.A. 95-331, eff. 8-21-07; 95-793, eff. 1-1-09.)
| ||||||
23 | Article 90. | ||||||
24 | Section 90-5. The Illinois Public Aid Code is amended by |
| |||||||
| |||||||
1 | adding Section 5-43 as follows:
| ||||||
2 | (305 ILCS 5/5-43 new) | ||||||
3 | Sec. 5-43. Supports Waiver Program for Young Adults with | ||||||
4 | Developmental Disabilities. | ||||||
5 | (a) The Department of Human Services' Division of | ||||||
6 | Developmental Disabilities, in partnership with the Department | ||||||
7 | of Healthcare and Family Services and stakeholders, shall | ||||||
8 | study the development and implementation of a supports waiver | ||||||
9 | program for young adults with developmental disabilities. The | ||||||
10 | Division shall explore the following components of a supports | ||||||
11 | waiver program to determine what is most appropriate: | ||||||
12 | (1) The age of individuals to be provided services in | ||||||
13 | a waiver program. | ||||||
14 | (2) The number of individuals to be provided services | ||||||
15 | in a waiver program. | ||||||
16 | (3) The services to be provided in a waiver program. | ||||||
17 | (4) The funding to be provided to individuals within a | ||||||
18 | waiver program. | ||||||
19 | (5) The transition process to the Waiver for Adults | ||||||
20 | with Developmental Disabilities. | ||||||
21 | (6) The type of home and community-based services | ||||||
22 | waiver to be utilized. | ||||||
23 | (b) The Department of Human Services and the Department of | ||||||
24 | Healthcare and Family Services are authorized to adopt and | ||||||
25 | implement any rules necessary to study the supports waiver |
| |||||||
| |||||||
1 | program. | ||||||
2 | (c) Subject to appropriation, no later than January 1, | ||||||
3 | 2024, the Department of Healthcare and Family Services shall | ||||||
4 | apply to the federal Centers for Medicare and Medicaid | ||||||
5 | Services for a supports waiver for young adults with | ||||||
6 | developmental disabilities utilizing the information learned | ||||||
7 | from the study under subsection (a).
| ||||||
8 | Article 95. | ||||||
9 | Section 95-5. The Illinois Public Aid Code is amended by | ||||||
10 | adding Section 5-5.06a as follows:
| ||||||
11 | (305 ILCS 5/5-5.06a new) | ||||||
12 | Sec. 5-5.06a. Increased funding for dental services. | ||||||
13 | Beginning January 1, 2022, the amount allocated to fund rates | ||||||
14 | for dental services provided to adults and children under the | ||||||
15 | medical assistance program shall be increased by an | ||||||
16 | approximate amount of $10,000,000.
| ||||||
17 | Article 105. | ||||||
18 | Section 105-5. The Illinois Public Aid Code is amended by | ||||||
19 | changing Section 5-30.1 as follows:
| ||||||
20 | (305 ILCS 5/5-30.1) |
| |||||||
| |||||||
1 | Sec. 5-30.1. Managed care protections. | ||||||
2 | (a) As used in this Section: | ||||||
3 | "Managed care organization" or "MCO" means any entity | ||||||
4 | which contracts with the Department to provide services where | ||||||
5 | payment for medical services is made on a capitated basis. | ||||||
6 | "Emergency services" include: | ||||||
7 | (1) emergency services, as defined by Section 10 of | ||||||
8 | the Managed Care Reform and Patient Rights Act; | ||||||
9 | (2) emergency medical screening examinations, as | ||||||
10 | defined by Section 10 of the Managed Care Reform and | ||||||
11 | Patient Rights Act; | ||||||
12 | (3) post-stabilization medical services, as defined by | ||||||
13 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
14 | Act; and | ||||||
15 | (4) emergency medical conditions, as defined by
| ||||||
16 | Section 10 of the Managed Care Reform and Patient Rights
| ||||||
17 | Act. | ||||||
18 | (b) As provided by Section 5-16.12, managed care | ||||||
19 | organizations are subject to the provisions of the Managed | ||||||
20 | Care Reform and Patient Rights Act. | ||||||
21 | (c) An MCO shall pay any provider of emergency services | ||||||
22 | that does not have in effect a contract with the contracted | ||||||
23 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
24 | rate paid under Illinois Medicaid fee-for-service program | ||||||
25 | methodology, including all policy adjusters, including but not | ||||||
26 | limited to Medicaid High Volume Adjustments, Medicaid |
| |||||||
| |||||||
1 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
2 | and all outlier add-on adjustments to the extent such | ||||||
3 | adjustments are incorporated in the development of the | ||||||
4 | applicable MCO capitated rates. | ||||||
5 | (d) An MCO shall pay for all post-stabilization services | ||||||
6 | as a covered service in any of the following situations: | ||||||
7 | (1) the MCO authorized such services; | ||||||
8 | (2) such services were administered to maintain the | ||||||
9 | enrollee's stabilized condition within one hour after a | ||||||
10 | request to the MCO for authorization of further | ||||||
11 | post-stabilization services; | ||||||
12 | (3) the MCO did not respond to a request to authorize | ||||||
13 | such services within one hour; | ||||||
14 | (4) the MCO could not be contacted; or | ||||||
15 | (5) the MCO and the treating provider, if the treating | ||||||
16 | provider is a non-affiliated provider, could not reach an | ||||||
17 | agreement concerning the enrollee's care and an affiliated | ||||||
18 | provider was unavailable for a consultation, in which case | ||||||
19 | the MCO
must pay for such services rendered by the | ||||||
20 | treating non-affiliated provider until an affiliated | ||||||
21 | provider was reached and either concurred with the | ||||||
22 | treating non-affiliated provider's plan of care or assumed | ||||||
23 | responsibility for the enrollee's care. Such payment shall | ||||||
24 | be made at the default rate of reimbursement paid under | ||||||
25 | Illinois Medicaid fee-for-service program methodology, | ||||||
26 | including all policy adjusters, including but not limited |
| |||||||
| |||||||
1 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
2 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
3 | outlier add-on adjustments to the extent that such | ||||||
4 | adjustments are incorporated in the development of the | ||||||
5 | applicable MCO capitated rates. | ||||||
6 | (e) The following requirements apply to MCOs in | ||||||
7 | determining payment for all emergency services: | ||||||
8 | (1) MCOs shall not impose any requirements for prior | ||||||
9 | approval of emergency services. | ||||||
10 | (2) The MCO shall cover emergency services provided to | ||||||
11 | enrollees who are temporarily away from their residence | ||||||
12 | and outside the contracting area to the extent that the | ||||||
13 | enrollees would be entitled to the emergency services if | ||||||
14 | they still were within the contracting area. | ||||||
15 | (3) The MCO shall have no obligation to cover medical | ||||||
16 | services provided on an emergency basis that are not | ||||||
17 | covered services under the contract. | ||||||
18 | (4) The MCO shall not condition coverage for emergency | ||||||
19 | services on the treating provider notifying the MCO of the | ||||||
20 | enrollee's screening and treatment within 10 days after | ||||||
21 | presentation for emergency services. | ||||||
22 | (5) The determination of the attending emergency | ||||||
23 | physician, or the provider actually treating the enrollee, | ||||||
24 | of whether an enrollee is sufficiently stabilized for | ||||||
25 | discharge or transfer to another facility, shall be | ||||||
26 | binding on the MCO. The MCO shall cover emergency services |
| |||||||
| |||||||
1 | for all enrollees whether the emergency services are | ||||||
2 | provided by an affiliated or non-affiliated provider. | ||||||
3 | (6) The MCO's financial responsibility for | ||||||
4 | post-stabilization care services it has not pre-approved | ||||||
5 | ends when: | ||||||
6 | (A) a plan physician with privileges at the | ||||||
7 | treating hospital assumes responsibility for the | ||||||
8 | enrollee's care; | ||||||
9 | (B) a plan physician assumes responsibility for | ||||||
10 | the enrollee's care through transfer; | ||||||
11 | (C) a contracting entity representative and the | ||||||
12 | treating physician reach an agreement concerning the | ||||||
13 | enrollee's care; or | ||||||
14 | (D) the enrollee is discharged. | ||||||
15 | (f) Network adequacy and transparency. | ||||||
16 | (1) The Department shall: | ||||||
17 | (A) ensure that an adequate provider network is in | ||||||
18 | place, taking into consideration health professional | ||||||
19 | shortage areas and medically underserved areas; | ||||||
20 | (B) publicly release an explanation of its process | ||||||
21 | for analyzing network adequacy; | ||||||
22 | (C) periodically ensure that an MCO continues to | ||||||
23 | have an adequate network in place; | ||||||
24 | (D) require MCOs, including Medicaid Managed Care | ||||||
25 | Entities as defined in Section 5-30.2, to meet | ||||||
26 | provider directory requirements under Section 5-30.3; |
| |||||||
| |||||||
1 | and | ||||||
2 | (E) require MCOs to ensure that any | ||||||
3 | Medicaid-certified provider
under contract with an MCO | ||||||
4 | and previously submitted on a roster on the date of | ||||||
5 | service is
paid for any medically necessary, | ||||||
6 | Medicaid-covered, and authorized service rendered to
| ||||||
7 | any of the MCO's enrollees, regardless of inclusion on
| ||||||
8 | the MCO's published and publicly available directory | ||||||
9 | of
available providers. | ||||||
10 | (2) Each MCO shall confirm its receipt of information | ||||||
11 | submitted specific to physician or dentist additions or | ||||||
12 | physician or dentist deletions from the MCO's provider | ||||||
13 | network within 3 days after receiving all required | ||||||
14 | information from contracted physicians or dentists, and | ||||||
15 | electronic physician and dental directories must be | ||||||
16 | updated consistent with current rules as published by the | ||||||
17 | Centers for Medicare and Medicaid Services or its | ||||||
18 | successor agency. | ||||||
19 | (g) Timely payment of claims. | ||||||
20 | (1) The MCO shall pay a claim within 30 days of | ||||||
21 | receiving a claim that contains all the essential | ||||||
22 | information needed to adjudicate the claim. | ||||||
23 | (2) The MCO shall notify the billing party of its | ||||||
24 | inability to adjudicate a claim within 30 days of | ||||||
25 | receiving that claim. | ||||||
26 | (3) The MCO shall pay a penalty that is at least equal |
| |||||||
| |||||||
1 | to the timely payment interest penalty imposed under | ||||||
2 | Section 368a of the Illinois Insurance Code for any claims | ||||||
3 | not timely paid. | ||||||
4 | (A) When an MCO is required to pay a timely payment | ||||||
5 | interest penalty to a provider, the MCO must calculate | ||||||
6 | and pay the timely payment interest penalty that is | ||||||
7 | due to the provider within 30 days after the payment of | ||||||
8 | the claim. In no event shall a provider be required to | ||||||
9 | request or apply for payment of any owed timely | ||||||
10 | payment interest penalties. | ||||||
11 | (B) Such payments shall be reported separately | ||||||
12 | from the claim payment for services rendered to the | ||||||
13 | MCO's enrollee and clearly identified as interest | ||||||
14 | payments. | ||||||
15 | (4)(A) The Department shall require MCOs to expedite | ||||||
16 | payments to providers identified on the Department's | ||||||
17 | expedited provider list, determined in accordance with 89 | ||||||
18 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
19 | frequently as the providers are paid under the | ||||||
20 | Department's fee-for-service expedited provider schedule. | ||||||
21 | (B) Compliance with the expedited provider requirement | ||||||
22 | may be satisfied by an MCO through the use of a Periodic | ||||||
23 | Interim Payment (PIP) program that has been mutually | ||||||
24 | agreed to and documented between the MCO and the provider, | ||||||
25 | if the PIP program ensures that any expedited provider | ||||||
26 | receives regular and periodic payments based on prior |
| |||||||
| |||||||
1 | period payment experience from that MCO. Total payments | ||||||
2 | under the PIP program may be reconciled against future PIP | ||||||
3 | payments on a schedule mutually agreed to between the MCO | ||||||
4 | and the provider. | ||||||
5 | (C) The Department shall share at least monthly its | ||||||
6 | expedited provider list and the frequency with which it | ||||||
7 | pays providers on the expedited list. | ||||||
8 | (g-5) Recognizing that the rapid transformation of the | ||||||
9 | Illinois Medicaid program may have unintended operational | ||||||
10 | challenges for both payers and providers: | ||||||
11 | (1) in no instance shall a medically necessary covered | ||||||
12 | service rendered in good faith, based upon eligibility | ||||||
13 | information documented by the provider, be denied coverage | ||||||
14 | or diminished in payment amount if the eligibility or | ||||||
15 | coverage information available at the time the service was | ||||||
16 | rendered is later found to be inaccurate in the assignment | ||||||
17 | of coverage responsibility between MCOs or the | ||||||
18 | fee-for-service system, except for instances when an | ||||||
19 | individual is deemed to have not been eligible for | ||||||
20 | coverage under the Illinois Medicaid program; and | ||||||
21 | (2) the Department shall, by December 31, 2016, adopt | ||||||
22 | rules establishing policies that shall be included in the | ||||||
23 | Medicaid managed care policy and procedures manual | ||||||
24 | addressing payment resolutions in situations in which a | ||||||
25 | provider renders services based upon information obtained | ||||||
26 | after verifying a patient's eligibility and coverage plan |
| |||||||
| |||||||
1 | through either the Department's current enrollment system | ||||||
2 | or a system operated by the coverage plan identified by | ||||||
3 | the patient presenting for services: | ||||||
4 | (A) such medically necessary covered services | ||||||
5 | shall be considered rendered in good faith; | ||||||
6 | (B) such policies and procedures shall be | ||||||
7 | developed in consultation with industry | ||||||
8 | representatives of the Medicaid managed care health | ||||||
9 | plans and representatives of provider associations | ||||||
10 | representing the majority of providers within the | ||||||
11 | identified provider industry; and | ||||||
12 | (C) such rules shall be published for a review and | ||||||
13 | comment period of no less than 30 days on the | ||||||
14 | Department's website with final rules remaining | ||||||
15 | available on the Department's website. | ||||||
16 | The rules on payment resolutions shall include, but | ||||||
17 | not be limited to: | ||||||
18 | (A) the extension of the timely filing period; | ||||||
19 | (B) retroactive prior authorizations; and | ||||||
20 | (C) guaranteed minimum payment rate of no less | ||||||
21 | than the current, as of the date of service, | ||||||
22 | fee-for-service rate, plus all applicable add-ons, | ||||||
23 | when the resulting service relationship is out of | ||||||
24 | network. | ||||||
25 | The rules shall be applicable for both MCO coverage | ||||||
26 | and fee-for-service coverage. |
| |||||||
| |||||||
1 | If the fee-for-service system is ultimately determined to | ||||||
2 | have been responsible for coverage on the date of service, the | ||||||
3 | Department shall provide for an extended period for claims | ||||||
4 | submission outside the standard timely filing requirements. | ||||||
5 | (g-6) MCO Performance Metrics Report. | ||||||
6 | (1) The Department shall publish, on at least a | ||||||
7 | quarterly basis, each MCO's operational performance, | ||||||
8 | including, but not limited to, the following categories of | ||||||
9 | metrics: | ||||||
10 | (A) claims payment, including timeliness and | ||||||
11 | accuracy; | ||||||
12 | (B) prior authorizations; | ||||||
13 | (C) grievance and appeals; | ||||||
14 | (D) utilization statistics; | ||||||
15 | (E) provider disputes; | ||||||
16 | (F) provider credentialing; and | ||||||
17 | (G) member and provider customer service. | ||||||
18 | (2) The Department shall ensure that the metrics | ||||||
19 | report is accessible to providers online by January 1, | ||||||
20 | 2017. | ||||||
21 | (3) The metrics shall be developed in consultation | ||||||
22 | with industry representatives of the Medicaid managed care | ||||||
23 | health plans and representatives of associations | ||||||
24 | representing the majority of providers within the | ||||||
25 | identified industry. | ||||||
26 | (4) Metrics shall be defined and incorporated into the |
| |||||||
| |||||||
1 | applicable Managed Care Policy Manual issued by the | ||||||
2 | Department. | ||||||
3 | (g-7) MCO claims processing and performance analysis. In | ||||||
4 | order to monitor MCO payments to hospital providers, pursuant | ||||||
5 | to this amendatory Act of the 100th General Assembly, the | ||||||
6 | Department shall post an analysis of MCO claims processing and | ||||||
7 | payment performance on its website every 6 months. Such | ||||||
8 | analysis shall include a review and evaluation of a | ||||||
9 | representative sample of hospital claims that are rejected and | ||||||
10 | denied for clean and unclean claims and the top 5 reasons for | ||||||
11 | such actions and timeliness of claims adjudication, which | ||||||
12 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
13 | 90, and over 90 days, and the dollar amounts associated with | ||||||
14 | those claims. The Department shall post the contracted claims | ||||||
15 | report required by HealthChoice Illinois on its website every | ||||||
16 | 3 months. | ||||||
17 | (g-8) Dispute resolution process. The Department shall | ||||||
18 | maintain a provider complaint portal through which a provider | ||||||
19 | can submit to the Department unresolved disputes with an MCO. | ||||||
20 | An unresolved dispute means an MCO's decision that denies in | ||||||
21 | whole or in part a claim for reimbursement to a provider for | ||||||
22 | health care services rendered by the provider to an enrollee | ||||||
23 | of the MCO with which the provider disagrees. Disputes shall | ||||||
24 | not be submitted to the portal until the provider has availed | ||||||
25 | itself of the MCO's internal dispute resolution process. | ||||||
26 | Disputes that are submitted to the MCO internal dispute |
| |||||||
| |||||||
1 | resolution process may be submitted to the Department of | ||||||
2 | Healthcare and Family Services' complaint portal no sooner | ||||||
3 | than 30 days after submitting to the MCO's internal process | ||||||
4 | and not later than 30 days after the unsatisfactory resolution | ||||||
5 | of the internal MCO process or 60 days after submitting the | ||||||
6 | dispute to the MCO internal process. Multiple claim disputes | ||||||
7 | involving the same MCO may be submitted in one complaint, | ||||||
8 | regardless of whether the claims are for different enrollees, | ||||||
9 | when the specific reason for non-payment of the claims | ||||||
10 | involves a common question of fact or policy. Within 10 | ||||||
11 | business days of receipt of a complaint, the Department shall | ||||||
12 | present such disputes to the appropriate MCO, which shall then | ||||||
13 | have 30 days to issue its written proposal to resolve the | ||||||
14 | dispute. The Department may grant one 30-day extension of this | ||||||
15 | time frame to one of the parties to resolve the dispute. If the | ||||||
16 | dispute remains unresolved at the end of this time frame or the | ||||||
17 | provider is not satisfied with the MCO's written proposal to | ||||||
18 | resolve the dispute, the provider may, within 30 days, request | ||||||
19 | the Department to review the dispute and make a final | ||||||
20 | determination. Within 30 days of the request for Department | ||||||
21 | review of the dispute, both the provider and the MCO shall | ||||||
22 | present all relevant information to the Department for | ||||||
23 | resolution and make individuals with knowledge of the issues | ||||||
24 | available to the Department for further inquiry if needed. | ||||||
25 | Within 30 days of receiving the relevant information on the | ||||||
26 | dispute, or the lapse of the period for submitting such |
| |||||||
| |||||||
1 | information, the Department shall issue a written decision on | ||||||
2 | the dispute based on contractual terms between the provider | ||||||
3 | and the MCO, contractual terms between the MCO and the | ||||||
4 | Department of Healthcare and Family Services and applicable | ||||||
5 | Medicaid policy. The decision of the Department shall be | ||||||
6 | final. By January 1, 2020, the Department shall establish by | ||||||
7 | rule further details of this dispute resolution process. | ||||||
8 | Disputes between MCOs and providers presented to the | ||||||
9 | Department for resolution are not contested cases, as defined | ||||||
10 | in Section 1-30 of the Illinois Administrative Procedure Act, | ||||||
11 | conferring any right to an administrative hearing. | ||||||
12 | (g-9)(1) The Department shall publish annually on its | ||||||
13 | website a report on the calculation of each managed care | ||||||
14 | organization's medical loss ratio showing the following: | ||||||
15 | (A) Premium revenue, with appropriate adjustments. | ||||||
16 | (B) Benefit expense, setting forth the aggregate | ||||||
17 | amount spent for the following: | ||||||
18 | (i) Direct paid claims. | ||||||
19 | (ii) Subcapitation payments. | ||||||
20 | (iii)
Other claim payments. | ||||||
21 | (iv)
Direct reserves. | ||||||
22 | (v)
Gross recoveries. | ||||||
23 | (vi)
Expenses for activities that improve health | ||||||
24 | care quality as allowed by the Department. | ||||||
25 | (2) The medical loss ratio shall be calculated consistent | ||||||
26 | with federal law and regulation following a claims runout |
| |||||||
| |||||||
1 | period determined by the Department. | ||||||
2 | (g-10)(1) "Liability effective date" means the date on | ||||||
3 | which an MCO becomes responsible for payment for medically | ||||||
4 | necessary and covered services rendered by a provider to one | ||||||
5 | of its enrollees in accordance with the contract terms between | ||||||
6 | the MCO and the provider. The liability effective date shall | ||||||
7 | be the later of: | ||||||
8 | (A) The execution date of a network participation | ||||||
9 | contract agreement. | ||||||
10 | (B) The date the provider or its representative | ||||||
11 | submits to the MCO the complete and accurate standardized | ||||||
12 | roster form for the provider in the format approved by the | ||||||
13 | Department. | ||||||
14 | (C) The provider effective date contained within the | ||||||
15 | Department's provider enrollment subsystem within the | ||||||
16 | Illinois Medicaid Program Advanced Cloud Technology | ||||||
17 | (IMPACT) System. | ||||||
18 | (2) The standardized roster form may be submitted to the | ||||||
19 | MCO at the same time that the provider submits an enrollment | ||||||
20 | application to the Department through IMPACT. | ||||||
21 | (3) By October 1, 2019, the Department shall require all | ||||||
22 | MCOs to update their provider directory with information for | ||||||
23 | new practitioners of existing contracted providers within 30 | ||||||
24 | days of receipt of a complete and accurate standardized roster | ||||||
25 | template in the format approved by the Department provided | ||||||
26 | that the provider is effective in the Department's provider |
| |||||||
| |||||||
1 | enrollment subsystem within the IMPACT system. Such provider | ||||||
2 | directory shall be readily accessible for purposes of | ||||||
3 | selecting an approved health care provider and comply with all | ||||||
4 | other federal and State requirements. | ||||||
5 | (g-11) The Department shall work with relevant | ||||||
6 | stakeholders on the development of operational guidelines to | ||||||
7 | enhance and improve operational performance of Illinois' | ||||||
8 | Medicaid managed care program, including, but not limited to, | ||||||
9 | improving provider billing practices, reducing claim | ||||||
10 | rejections and inappropriate payment denials, and | ||||||
11 | standardizing processes, procedures, definitions, and response | ||||||
12 | timelines, with the goal of reducing provider and MCO | ||||||
13 | administrative burdens and conflict. The Department shall | ||||||
14 | include a report on the progress of these program improvements | ||||||
15 | and other topics in its Fiscal Year 2020 annual report to the | ||||||
16 | General Assembly. | ||||||
17 | (g-12) Notwithstanding any other provision of law, if the
| ||||||
18 | Department or an MCO requires submission of a claim for | ||||||
19 | payment
in a non-electronic format, a provider shall always be | ||||||
20 | afforded
a period of no less than 90 business days, as a | ||||||
21 | correction
period, following any notification of rejection by | ||||||
22 | either the
Department or the MCO to correct errors or | ||||||
23 | omissions in the
original submission. | ||||||
24 | Under no circumstances, either by an MCO or under the
| ||||||
25 | State's fee-for-service system, shall a provider be denied
| ||||||
26 | payment for failure to comply with any timely submission
|
| |||||||
| |||||||
1 | requirements under this Code or under any existing contract,
| ||||||
2 | unless the non-electronic format claim submission occurs after
| ||||||
3 | the initial 180 days following the latest date of service on
| ||||||
4 | the claim, or after the 90 business days correction period
| ||||||
5 | following notification to the provider of rejection or denial
| ||||||
6 | of payment. | ||||||
7 | (h) The Department shall not expand mandatory MCO | ||||||
8 | enrollment into new counties beyond those counties already | ||||||
9 | designated by the Department as of June 1, 2014 for the | ||||||
10 | individuals whose eligibility for medical assistance is not | ||||||
11 | the seniors or people with disabilities population until the | ||||||
12 | Department provides an opportunity for accountable care | ||||||
13 | entities and MCOs to participate in such newly designated | ||||||
14 | counties. | ||||||
15 | (i) The requirements of this Section apply to contracts | ||||||
16 | with accountable care entities and MCOs entered into, amended, | ||||||
17 | or renewed after June 16, 2014 (the effective date of Public | ||||||
18 | Act 98-651).
| ||||||
19 | (j) Health care information released to managed care | ||||||
20 | organizations. A health care provider shall release to a | ||||||
21 | Medicaid managed care organization, upon request, and subject | ||||||
22 | to the Health Insurance Portability and Accountability Act of | ||||||
23 | 1996 and any other law applicable to the release of health | ||||||
24 | information, the health care information of the MCO's | ||||||
25 | enrollee, if the enrollee has completed and signed a general | ||||||
26 | release form that grants to the health care provider |
| |||||||
| |||||||
1 | permission to release the recipient's health care information | ||||||
2 | to the recipient's insurance carrier. | ||||||
3 | (k) The Department of Healthcare and Family Services, | ||||||
4 | managed care organizations, a statewide organization | ||||||
5 | representing hospitals, and a statewide organization | ||||||
6 | representing safety-net hospitals shall explore ways to | ||||||
7 | support billing departments in safety-net hospitals. | ||||||
8 | (l) The requirements of this Section added by this
| ||||||
9 | amendatory Act of the 102nd General Assembly shall apply to
| ||||||
10 | services provided on or after the first day of the month that
| ||||||
11 | begins 60 days after the effective date of this amendatory Act
| ||||||
12 | of the 102nd General Assembly. | ||||||
13 | (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
| ||||||
14 | Article 999.
| ||||||
15 | Section 999-99. Effective date. This Act takes effect upon | ||||||
16 | becoming law.
|