Rep. Robyn Gabel
Filed: 5/28/2021
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1 | AMENDMENT TO SENATE BILL 2384
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2 | AMENDMENT NO. ______. Amend Senate Bill 2384 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 1. Amends the Illinois Public Aid Code is amended | ||||||
5 | by changing Section 5-5 as follows:
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6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||
10 | will be authorized, and the medical services to be provided,
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11 | which may include all or part of the following: (1) inpatient | ||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||
15 | office, the patient's home, a
hospital, a skilled nursing | ||||||
16 | home, or elsewhere; (6) medical care, or any
other type of |
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1 | remedial care furnished by licensed practitioners; (7)
home | ||||||
2 | health care services; (8) private duty nursing service; (9) | ||||||
3 | clinic
services; (10) dental services, including prevention | ||||||
4 | and treatment of periodontal disease and dental caries disease | ||||||
5 | for pregnant women, provided by an individual licensed to | ||||||
6 | practice dentistry or dental surgery; for purposes of this | ||||||
7 | item (10), "dental services" means diagnostic, preventive, or | ||||||
8 | corrective procedures provided by or under the supervision of | ||||||
9 | a dentist in the practice of his or her profession; (11) | ||||||
10 | physical therapy and related
services; (12) prescribed drugs, | ||||||
11 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
12 | a physician skilled in the diseases of the eye,
or by an | ||||||
13 | optometrist, whichever the person may select; (13) other
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14 | diagnostic, screening, preventive, and rehabilitative | ||||||
15 | services, including to ensure that the individual's need for | ||||||
16 | intervention or treatment of mental disorders or substance use | ||||||
17 | disorders or co-occurring mental health and substance use | ||||||
18 | disorders is determined using a uniform screening, assessment, | ||||||
19 | and evaluation process inclusive of criteria, for children and | ||||||
20 | adults; for purposes of this item (13), a uniform screening, | ||||||
21 | assessment, and evaluation process refers to a process that | ||||||
22 | includes an appropriate evaluation and, as warranted, a | ||||||
23 | referral; "uniform" does not mean the use of a singular | ||||||
24 | instrument, tool, or process that all must utilize; (14)
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25 | transportation and such other expenses as may be necessary; | ||||||
26 | (15) medical
treatment of sexual assault survivors, as defined |
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1 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
2 | Treatment Act, for
injuries sustained as a result of the | ||||||
3 | sexual assault, including
examinations and laboratory tests to | ||||||
4 | discover evidence which may be used in
criminal proceedings | ||||||
5 | arising from the sexual assault; (16) the
diagnosis and | ||||||
6 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
7 | care, and any other type of remedial care recognized
under the | ||||||
8 | laws of this State. The term "any other type of remedial care" | ||||||
9 | shall
include nursing care and nursing home service for | ||||||
10 | persons who rely on
treatment by spiritual means alone through | ||||||
11 | prayer for healing.
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12 | Notwithstanding any other provision of this Section, a | ||||||
13 | comprehensive
tobacco use cessation program that includes | ||||||
14 | purchasing prescription drugs or
prescription medical devices | ||||||
15 | approved by the Food and Drug Administration shall
be covered | ||||||
16 | under the medical assistance
program under this Article for | ||||||
17 | persons who are otherwise eligible for
assistance under this | ||||||
18 | Article.
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19 | Notwithstanding any other provision of this Code, | ||||||
20 | reproductive health care that is otherwise legal in Illinois | ||||||
21 | shall be covered under the medical assistance program for | ||||||
22 | persons who are otherwise eligible for medical assistance | ||||||
23 | under this Article. | ||||||
24 | Notwithstanding any other provision of this Code, the | ||||||
25 | Illinois
Department may not require, as a condition of payment | ||||||
26 | for any laboratory
test authorized under this Article, that a |
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1 | physician's handwritten signature
appear on the laboratory | ||||||
2 | test order form. The Illinois Department may,
however, impose | ||||||
3 | other appropriate requirements regarding laboratory test
order | ||||||
4 | documentation.
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5 | Upon receipt of federal approval of an amendment to the | ||||||
6 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
7 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
8 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
9 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
10 | that its vendor or vendors are enrolled as providers in the | ||||||
11 | medical assistance program and in any capitated Medicaid | ||||||
12 | managed care entity (MCE) serving individuals enrolled in a | ||||||
13 | school within the CPS system. Under any contract procured | ||||||
14 | under this provision, the vendor or vendors must serve only | ||||||
15 | individuals enrolled in a school within the CPS system. Claims | ||||||
16 | for services provided by CPS's vendor or vendors to recipients | ||||||
17 | of benefits in the medical assistance program under this Code, | ||||||
18 | the Children's Health Insurance Program, or the Covering ALL | ||||||
19 | KIDS Health Insurance Program shall be submitted to the | ||||||
20 | Department or the MCE in which the individual is enrolled for | ||||||
21 | payment and shall be reimbursed at the Department's or the | ||||||
22 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
23 | On and after July 1, 2012, the Department of Healthcare | ||||||
24 | and Family Services may provide the following services to
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25 | persons
eligible for assistance under this Article who are | ||||||
26 | participating in
education, training or employment programs |
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1 | operated by the Department of Human
Services as successor to | ||||||
2 | the Department of Public Aid:
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3 | (1) dental services provided by or under the | ||||||
4 | supervision of a dentist; and
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5 | (2) eyeglasses prescribed by a physician skilled in | ||||||
6 | the diseases of the
eye, or by an optometrist, whichever | ||||||
7 | the person may select.
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8 | On and after July 1, 2018, the Department of Healthcare | ||||||
9 | and Family Services shall provide dental services to any adult | ||||||
10 | who is otherwise eligible for assistance under the medical | ||||||
11 | assistance program. As used in this paragraph, "dental | ||||||
12 | services" means diagnostic, preventative, restorative, or | ||||||
13 | corrective procedures, including procedures and services for | ||||||
14 | the prevention and treatment of periodontal disease and dental | ||||||
15 | caries disease, provided by an individual who is licensed to | ||||||
16 | practice dentistry or dental surgery or who is under the | ||||||
17 | supervision of a dentist in the practice of his or her | ||||||
18 | profession. | ||||||
19 | On and after July 1, 2018, targeted dental services, as | ||||||
20 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
21 | United States District Court for the Northern District of | ||||||
22 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
23 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
24 | the medical assistance program shall be established at no less | ||||||
25 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
26 | of the Consent Decree for targeted dental services that are |
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1 | provided to persons under the age of 18 under the medical | ||||||
2 | assistance program. | ||||||
3 | Notwithstanding any other provision of this Code and | ||||||
4 | subject to federal approval, the Department may adopt rules to | ||||||
5 | allow a dentist who is volunteering his or her service at no | ||||||
6 | cost to render dental services through an enrolled | ||||||
7 | not-for-profit health clinic without the dentist personally | ||||||
8 | enrolling as a participating provider in the medical | ||||||
9 | assistance program. A not-for-profit health clinic shall | ||||||
10 | include a public health clinic or Federally Qualified Health | ||||||
11 | Center or other enrolled provider, as determined by the | ||||||
12 | Department, through which dental services covered under this | ||||||
13 | Section are performed. The Department shall establish a | ||||||
14 | process for payment of claims for reimbursement for covered | ||||||
15 | dental services rendered under this provision. | ||||||
16 | The Illinois Department, by rule, may distinguish and | ||||||
17 | classify the
medical services to be provided only in | ||||||
18 | accordance with the classes of
persons designated in Section | ||||||
19 | 5-2.
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20 | The Department of Healthcare and Family Services must | ||||||
21 | provide coverage and reimbursement for amino acid-based | ||||||
22 | elemental formulas, regardless of delivery method, for the | ||||||
23 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
24 | short bowel syndrome when the prescribing physician has issued | ||||||
25 | a written order stating that the amino acid-based elemental | ||||||
26 | formula is medically necessary.
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1 | The Illinois Department shall authorize the provision of, | ||||||
2 | and shall
authorize payment for, screening by low-dose | ||||||
3 | mammography for the presence of
occult breast cancer for women | ||||||
4 | 35 years of age or older who are eligible
for medical | ||||||
5 | assistance under this Article, as follows: | ||||||
6 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
7 | age.
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8 | (B) An annual mammogram for women 40 years of age or | ||||||
9 | older. | ||||||
10 | (C) A mammogram at the age and intervals considered | ||||||
11 | medically necessary by the woman's health care provider | ||||||
12 | for women under 40 years of age and having a family history | ||||||
13 | of breast cancer, prior personal history of breast cancer, | ||||||
14 | positive genetic testing, or other risk factors. | ||||||
15 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
16 | entire breast or breasts if a mammogram demonstrates | ||||||
17 | heterogeneous or dense breast tissue or when medically | ||||||
18 | necessary as determined by a physician licensed to | ||||||
19 | practice medicine in all of its branches. | ||||||
20 | (E) A screening MRI when medically necessary, as | ||||||
21 | determined by a physician licensed to practice medicine in | ||||||
22 | all of its branches. | ||||||
23 | (F) A diagnostic mammogram when medically necessary, | ||||||
24 | as determined by a physician licensed to practice medicine | ||||||
25 | in all its branches, advanced practice registered nurse, | ||||||
26 | or physician assistant. |
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1 | The Department shall not impose a deductible, coinsurance, | ||||||
2 | copayment, or any other cost-sharing requirement on the | ||||||
3 | coverage provided under this paragraph; except that this | ||||||
4 | sentence does not apply to coverage of diagnostic mammograms | ||||||
5 | to the extent such coverage would disqualify a high-deductible | ||||||
6 | health plan from eligibility for a health savings account | ||||||
7 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
8 | U.S.C. 223). | ||||||
9 | All screenings
shall
include a physical breast exam, | ||||||
10 | instruction on self-examination and
information regarding the | ||||||
11 | frequency of self-examination and its value as a
preventative | ||||||
12 | tool. | ||||||
13 | For purposes of this Section: | ||||||
14 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
15 | diagnostic mammography. | ||||||
16 | "Diagnostic
mammography" means a method of screening that | ||||||
17 | is designed to
evaluate an abnormality in a breast, including | ||||||
18 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
19 | subjective or objective
abnormality otherwise detected in the | ||||||
20 | breast. | ||||||
21 | "Low-dose mammography" means
the x-ray examination of the | ||||||
22 | breast using equipment dedicated specifically
for mammography, | ||||||
23 | including the x-ray tube, filter, compression device,
and | ||||||
24 | image receptor, with an average radiation exposure delivery
of | ||||||
25 | less than one rad per breast for 2 views of an average size | ||||||
26 | breast.
The term also includes digital mammography and |
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1 | includes breast tomosynthesis. | ||||||
2 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
3 | involves the acquisition of projection images over the | ||||||
4 | stationary breast to produce cross-sectional digital | ||||||
5 | three-dimensional images of the breast. | ||||||
6 | If, at any time, the Secretary of the United States | ||||||
7 | Department of Health and Human Services, or its successor | ||||||
8 | agency, promulgates rules or regulations to be published in | ||||||
9 | the Federal Register or publishes a comment in the Federal | ||||||
10 | Register or issues an opinion, guidance, or other action that | ||||||
11 | would require the State, pursuant to any provision of the | ||||||
12 | Patient Protection and Affordable Care Act (Public Law | ||||||
13 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
14 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
15 | of any coverage for breast tomosynthesis outlined in this | ||||||
16 | paragraph, then the requirement that an insurer cover breast | ||||||
17 | tomosynthesis is inoperative other than any such coverage | ||||||
18 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
19 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
20 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
21 | this paragraph.
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22 | On and after January 1, 2016, the Department shall ensure | ||||||
23 | that all networks of care for adult clients of the Department | ||||||
24 | include access to at least one breast imaging Center of | ||||||
25 | Imaging Excellence as certified by the American College of | ||||||
26 | Radiology. |
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1 | On and after January 1, 2012, providers participating in a | ||||||
2 | quality improvement program approved by the Department shall | ||||||
3 | be reimbursed for screening and diagnostic mammography at the | ||||||
4 | same rate as the Medicare program's rates, including the | ||||||
5 | increased reimbursement for digital mammography. | ||||||
6 | The Department shall convene an expert panel including | ||||||
7 | representatives of hospitals, free-standing mammography | ||||||
8 | facilities, and doctors, including radiologists, to establish | ||||||
9 | quality standards for mammography. | ||||||
10 | On and after January 1, 2017, providers participating in a | ||||||
11 | breast cancer treatment quality improvement program approved | ||||||
12 | by the Department shall be reimbursed for breast cancer | ||||||
13 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
14 | program's rates for the data elements included in the breast | ||||||
15 | cancer treatment quality program. | ||||||
16 | The Department shall convene an expert panel, including | ||||||
17 | representatives of hospitals, free-standing breast cancer | ||||||
18 | treatment centers, breast cancer quality organizations, and | ||||||
19 | doctors, including breast surgeons, reconstructive breast | ||||||
20 | surgeons, oncologists, and primary care providers to establish | ||||||
21 | quality standards for breast cancer treatment. | ||||||
22 | Subject to federal approval, the Department shall | ||||||
23 | establish a rate methodology for mammography at federally | ||||||
24 | qualified health centers and other encounter-rate clinics. | ||||||
25 | These clinics or centers may also collaborate with other | ||||||
26 | hospital-based mammography facilities. By January 1, 2016, the |
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1 | Department shall report to the General Assembly on the status | ||||||
2 | of the provision set forth in this paragraph. | ||||||
3 | The Department shall establish a methodology to remind | ||||||
4 | women who are age-appropriate for screening mammography, but | ||||||
5 | who have not received a mammogram within the previous 18 | ||||||
6 | months, of the importance and benefit of screening | ||||||
7 | mammography. The Department shall work with experts in breast | ||||||
8 | cancer outreach and patient navigation to optimize these | ||||||
9 | reminders and shall establish a methodology for evaluating | ||||||
10 | their effectiveness and modifying the methodology based on the | ||||||
11 | evaluation. | ||||||
12 | The Department shall establish a performance goal for | ||||||
13 | primary care providers with respect to their female patients | ||||||
14 | over age 40 receiving an annual mammogram. This performance | ||||||
15 | goal shall be used to provide additional reimbursement in the | ||||||
16 | form of a quality performance bonus to primary care providers | ||||||
17 | who meet that goal. | ||||||
18 | The Department shall devise a means of case-managing or | ||||||
19 | patient navigation for beneficiaries diagnosed with breast | ||||||
20 | cancer. This program shall initially operate as a pilot | ||||||
21 | program in areas of the State with the highest incidence of | ||||||
22 | mortality related to breast cancer. At least one pilot program | ||||||
23 | site shall be in the metropolitan Chicago area and at least one | ||||||
24 | site shall be outside the metropolitan Chicago area. On or | ||||||
25 | after July 1, 2016, the pilot program shall be expanded to | ||||||
26 | include one site in western Illinois, one site in southern |
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1 | Illinois, one site in central Illinois, and 4 sites within | ||||||
2 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
3 | be carried out measuring health outcomes and cost of care for | ||||||
4 | those served by the pilot program compared to similarly | ||||||
5 | situated patients who are not served by the pilot program. | ||||||
6 | The Department shall require all networks of care to | ||||||
7 | develop a means either internally or by contract with experts | ||||||
8 | in navigation and community outreach to navigate cancer | ||||||
9 | patients to comprehensive care in a timely fashion. The | ||||||
10 | Department shall require all networks of care to include | ||||||
11 | access for patients diagnosed with cancer to at least one | ||||||
12 | academic commission on cancer-accredited cancer program as an | ||||||
13 | in-network covered benefit. | ||||||
14 | Any medical or health care provider shall immediately | ||||||
15 | recommend, to
any pregnant woman who is being provided | ||||||
16 | prenatal services and is suspected
of having a substance use | ||||||
17 | disorder as defined in the Substance Use Disorder Act, | ||||||
18 | referral to a local substance use disorder treatment program | ||||||
19 | licensed by the Department of Human Services or to a licensed
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20 | hospital which provides substance abuse treatment services. | ||||||
21 | The Department of Healthcare and Family Services
shall assure | ||||||
22 | coverage for the cost of treatment of the drug abuse or
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23 | addiction for pregnant recipients in accordance with the | ||||||
24 | Illinois Medicaid
Program in conjunction with the Department | ||||||
25 | of Human Services.
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26 | All medical providers providing medical assistance to |
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1 | pregnant women
under this Code shall receive information from | ||||||
2 | the Department on the
availability of services under any
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3 | program providing case management services for addicted women,
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4 | including information on appropriate referrals for other | ||||||
5 | social services
that may be needed by addicted women in | ||||||
6 | addition to treatment for addiction.
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7 | The Illinois Department, in cooperation with the | ||||||
8 | Departments of Human
Services (as successor to the Department | ||||||
9 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
10 | a public awareness campaign, may
provide information | ||||||
11 | concerning treatment for alcoholism and drug abuse and
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12 | addiction, prenatal health care, and other pertinent programs | ||||||
13 | directed at
reducing the number of drug-affected infants born | ||||||
14 | to recipients of medical
assistance.
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15 | Neither the Department of Healthcare and Family Services | ||||||
16 | nor the Department of Human
Services shall sanction the | ||||||
17 | recipient solely on the basis of
her substance abuse.
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18 | The Illinois Department shall establish such regulations | ||||||
19 | governing
the dispensing of health services under this Article | ||||||
20 | as it shall deem
appropriate. The Department
should
seek the | ||||||
21 | advice of formal professional advisory committees appointed by
| ||||||
22 | the Director of the Illinois Department for the purpose of | ||||||
23 | providing regular
advice on policy and administrative matters, | ||||||
24 | information dissemination and
educational activities for | ||||||
25 | medical and health care providers, and
consistency in | ||||||
26 | procedures to the Illinois Department.
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1 | The Illinois Department may develop and contract with | ||||||
2 | Partnerships of
medical providers to arrange medical services | ||||||
3 | for persons eligible under
Section 5-2 of this Code. | ||||||
4 | Implementation of this Section may be by
demonstration | ||||||
5 | projects in certain geographic areas. The Partnership shall
be | ||||||
6 | represented by a sponsor organization. The Department, by | ||||||
7 | rule, shall
develop qualifications for sponsors of | ||||||
8 | Partnerships. Nothing in this
Section shall be construed to | ||||||
9 | require that the sponsor organization be a
medical | ||||||
10 | organization.
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11 | The sponsor must negotiate formal written contracts with | ||||||
12 | medical
providers for physician services, inpatient and | ||||||
13 | outpatient hospital care,
home health services, treatment for | ||||||
14 | alcoholism and substance abuse, and
other services determined | ||||||
15 | necessary by the Illinois Department by rule for
delivery by | ||||||
16 | Partnerships. Physician services must include prenatal and
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17 | obstetrical care. The Illinois Department shall reimburse | ||||||
18 | medical services
delivered by Partnership providers to clients | ||||||
19 | in target areas according to
provisions of this Article and | ||||||
20 | the Illinois Health Finance Reform Act,
except that:
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21 | (1) Physicians participating in a Partnership and | ||||||
22 | providing certain
services, which shall be determined by | ||||||
23 | the Illinois Department, to persons
in areas covered by | ||||||
24 | the Partnership may receive an additional surcharge
for | ||||||
25 | such services.
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26 | (2) The Department may elect to consider and negotiate |
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1 | financial
incentives to encourage the development of | ||||||
2 | Partnerships and the efficient
delivery of medical care.
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3 | (3) Persons receiving medical services through | ||||||
4 | Partnerships may receive
medical and case management | ||||||
5 | services above the level usually offered
through the | ||||||
6 | medical assistance program.
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7 | Medical providers shall be required to meet certain | ||||||
8 | qualifications to
participate in Partnerships to ensure the | ||||||
9 | delivery of high quality medical
services. These | ||||||
10 | qualifications shall be determined by rule of the Illinois
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11 | Department and may be higher than qualifications for | ||||||
12 | participation in the
medical assistance program. Partnership | ||||||
13 | sponsors may prescribe reasonable
additional qualifications | ||||||
14 | for participation by medical providers, only with
the prior | ||||||
15 | written approval of the Illinois Department.
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16 | Nothing in this Section shall limit the free choice of | ||||||
17 | practitioners,
hospitals, and other providers of medical | ||||||
18 | services by clients.
In order to ensure patient freedom of | ||||||
19 | choice, the Illinois Department shall
immediately promulgate | ||||||
20 | all rules and take all other necessary actions so that
| ||||||
21 | provided services may be accessed from therapeutically | ||||||
22 | certified optometrists
to the full extent of the Illinois | ||||||
23 | Optometric Practice Act of 1987 without
discriminating between | ||||||
24 | service providers.
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25 | The Department shall apply for a waiver from the United | ||||||
26 | States Health
Care Financing Administration to allow for the |
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1 | implementation of
Partnerships under this Section.
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2 | The Illinois Department shall require health care | ||||||
3 | providers to maintain
records that document the medical care | ||||||
4 | and services provided to recipients
of Medical Assistance | ||||||
5 | under this Article. Such records must be retained for a period | ||||||
6 | of not less than 6 years from the date of service or as | ||||||
7 | provided by applicable State law, whichever period is longer, | ||||||
8 | except that if an audit is initiated within the required | ||||||
9 | retention period then the records must be retained until the | ||||||
10 | audit is completed and every exception is resolved. The | ||||||
11 | Illinois Department shall
require health care providers to | ||||||
12 | make available, when authorized by the
patient, in writing, | ||||||
13 | the medical records in a timely fashion to other
health care | ||||||
14 | providers who are treating or serving persons eligible for
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15 | Medical Assistance under this Article. All dispensers of | ||||||
16 | medical services
shall be required to maintain and retain | ||||||
17 | business and professional records
sufficient to fully and | ||||||
18 | accurately document the nature, scope, details and
receipt of | ||||||
19 | the health care provided to persons eligible for medical
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20 | assistance under this Code, in accordance with regulations | ||||||
21 | promulgated by
the Illinois Department. The rules and | ||||||
22 | regulations shall require that proof
of the receipt of | ||||||
23 | prescription drugs, dentures, prosthetic devices and
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24 | eyeglasses by eligible persons under this Section accompany | ||||||
25 | each claim
for reimbursement submitted by the dispenser of | ||||||
26 | such medical services.
No such claims for reimbursement shall |
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1 | be approved for payment by the Illinois
Department without | ||||||
2 | such proof of receipt, unless the Illinois Department
shall | ||||||
3 | have put into effect and shall be operating a system of | ||||||
4 | post-payment
audit and review which shall, on a sampling | ||||||
5 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
6 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
7 | for which payment is being made are actually being
received by | ||||||
8 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
9 | (the effective date of Public Act 83-1439), the Illinois | ||||||
10 | Department shall establish a
current list of acquisition costs | ||||||
11 | for all prosthetic devices and any
other items recognized as | ||||||
12 | medical equipment and supplies reimbursable under
this Article | ||||||
13 | and shall update such list on a quarterly basis, except that
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14 | the acquisition costs of all prescription drugs shall be | ||||||
15 | updated no
less frequently than every 30 days as required by | ||||||
16 | Section 5-5.12.
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17 | Notwithstanding any other law to the contrary, the | ||||||
18 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
19 | (the effective date of Public Act 98-104), establish | ||||||
20 | procedures to permit skilled care facilities licensed under | ||||||
21 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
22 | reimbursement purposes. Following development of these | ||||||
23 | procedures, the Department shall, by July 1, 2016, test the | ||||||
24 | viability of the new system and implement any necessary | ||||||
25 | operational or structural changes to its information | ||||||
26 | technology platforms in order to allow for the direct |
| |||||||
| |||||||
1 | acceptance and payment of nursing home claims. | ||||||
2 | Notwithstanding any other law to the contrary, the | ||||||
3 | Illinois Department shall, within 365 days after August 15, | ||||||
4 | 2014 (the effective date of Public Act 98-963), establish | ||||||
5 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
6 | Community Care Act and MC/DD facilities licensed under the | ||||||
7 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
8 | purposes. Following development of these procedures, the | ||||||
9 | Department shall have an additional 365 days to test the | ||||||
10 | viability of the new system and to ensure that any necessary | ||||||
11 | operational or structural changes to its information | ||||||
12 | technology platforms are implemented. | ||||||
13 | The Illinois Department shall require all dispensers of | ||||||
14 | medical
services, other than an individual practitioner or | ||||||
15 | group of practitioners,
desiring to participate in the Medical | ||||||
16 | Assistance program
established under this Article to disclose | ||||||
17 | all financial, beneficial,
ownership, equity, surety or other | ||||||
18 | interests in any and all firms,
corporations, partnerships, | ||||||
19 | associations, business enterprises, joint
ventures, agencies, | ||||||
20 | institutions or other legal entities providing any
form of | ||||||
21 | health care services in this State under this Article.
| ||||||
22 | The Illinois Department may require that all dispensers of | ||||||
23 | medical
services desiring to participate in the medical | ||||||
24 | assistance program
established under this Article disclose, | ||||||
25 | under such terms and conditions as
the Illinois Department may | ||||||
26 | by rule establish, all inquiries from clients
and attorneys |
| |||||||
| |||||||
1 | regarding medical bills paid by the Illinois Department, which
| ||||||
2 | inquiries could indicate potential existence of claims or | ||||||
3 | liens for the
Illinois Department.
| ||||||
4 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
5 | period and shall be conditional for one year. During the | ||||||
6 | period of conditional enrollment, the Department may
terminate | ||||||
7 | the vendor's eligibility to participate in, or may disenroll | ||||||
8 | the vendor from, the medical assistance
program without cause. | ||||||
9 | Unless otherwise specified, such termination of eligibility or | ||||||
10 | disenrollment is not subject to the
Department's hearing | ||||||
11 | process.
However, a disenrolled vendor may reapply without | ||||||
12 | penalty.
| ||||||
13 | The Department has the discretion to limit the conditional | ||||||
14 | enrollment period for vendors based upon category of risk of | ||||||
15 | the vendor. | ||||||
16 | Prior to enrollment and during the conditional enrollment | ||||||
17 | period in the medical assistance program, all vendors shall be | ||||||
18 | subject to enhanced oversight, screening, and review based on | ||||||
19 | the risk of fraud, waste, and abuse that is posed by the | ||||||
20 | category of risk of the vendor. The Illinois Department shall | ||||||
21 | establish the procedures for oversight, screening, and review, | ||||||
22 | which may include, but need not be limited to: criminal and | ||||||
23 | financial background checks; fingerprinting; license, | ||||||
24 | certification, and authorization verifications; unscheduled or | ||||||
25 | unannounced site visits; database checks; prepayment audit | ||||||
26 | reviews; audits; payment caps; payment suspensions; and other |
| |||||||
| |||||||
1 | screening as required by federal or State law. | ||||||
2 | The Department shall define or specify the following: (i) | ||||||
3 | by provider notice, the "category of risk of the vendor" for | ||||||
4 | each type of vendor, which shall take into account the level of | ||||||
5 | screening applicable to a particular category of vendor under | ||||||
6 | federal law and regulations; (ii) by rule or provider notice, | ||||||
7 | the maximum length of the conditional enrollment period for | ||||||
8 | each category of risk of the vendor; and (iii) by rule, the | ||||||
9 | hearing rights, if any, afforded to a vendor in each category | ||||||
10 | of risk of the vendor that is terminated or disenrolled during | ||||||
11 | the conditional enrollment period. | ||||||
12 | To be eligible for payment consideration, a vendor's | ||||||
13 | payment claim or bill, either as an initial claim or as a | ||||||
14 | resubmitted claim following prior rejection, must be received | ||||||
15 | by the Illinois Department, or its fiscal intermediary, no | ||||||
16 | later than 180 days after the latest date on the claim on which | ||||||
17 | medical goods or services were provided, with the following | ||||||
18 | exceptions: | ||||||
19 | (1) In the case of a provider whose enrollment is in | ||||||
20 | process by the Illinois Department, the 180-day period | ||||||
21 | shall not begin until the date on the written notice from | ||||||
22 | the Illinois Department that the provider enrollment is | ||||||
23 | complete. | ||||||
24 | (2) In the case of errors attributable to the Illinois | ||||||
25 | Department or any of its claims processing intermediaries | ||||||
26 | which result in an inability to receive, process, or |
| |||||||
| |||||||
1 | adjudicate a claim, the 180-day period shall not begin | ||||||
2 | until the provider has been notified of the error. | ||||||
3 | (3) In the case of a provider for whom the Illinois | ||||||
4 | Department initiates the monthly billing process. | ||||||
5 | (4) In the case of a provider operated by a unit of | ||||||
6 | local government with a population exceeding 3,000,000 | ||||||
7 | when local government funds finance federal participation | ||||||
8 | for claims payments. | ||||||
9 | For claims for services rendered during a period for which | ||||||
10 | a recipient received retroactive eligibility, claims must be | ||||||
11 | filed within 180 days after the Department determines the | ||||||
12 | applicant is eligible. For claims for which the Illinois | ||||||
13 | Department is not the primary payer, claims must be submitted | ||||||
14 | to the Illinois Department within 180 days after the final | ||||||
15 | adjudication by the primary payer. | ||||||
16 | In the case of long term care facilities, within 45 | ||||||
17 | calendar days of receipt by the facility of required | ||||||
18 | prescreening information, new admissions with associated | ||||||
19 | admission documents shall be submitted through the Medical | ||||||
20 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
21 | Eligibility Verification (REV) System or shall be submitted | ||||||
22 | directly to the Department of Human Services using required | ||||||
23 | admission forms. Effective September
1, 2014, admission | ||||||
24 | documents, including all prescreening
information, must be | ||||||
25 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
26 | to an accepted transaction shall be retained by a facility to |
| |||||||
| |||||||
1 | verify timely submittal. Once an admission transaction has | ||||||
2 | been completed, all resubmitted claims following prior | ||||||
3 | rejection are subject to receipt no later than 180 days after | ||||||
4 | the admission transaction has been completed. | ||||||
5 | Claims that are not submitted and received in compliance | ||||||
6 | with the foregoing requirements shall not be eligible for | ||||||
7 | payment under the medical assistance program, and the State | ||||||
8 | shall have no liability for payment of those claims. | ||||||
9 | To the extent consistent with applicable information and | ||||||
10 | privacy, security, and disclosure laws, State and federal | ||||||
11 | agencies and departments shall provide the Illinois Department | ||||||
12 | access to confidential and other information and data | ||||||
13 | necessary to perform eligibility and payment verifications and | ||||||
14 | other Illinois Department functions. This includes, but is not | ||||||
15 | limited to: information pertaining to licensure; | ||||||
16 | certification; earnings; immigration status; citizenship; wage | ||||||
17 | reporting; unearned and earned income; pension income; | ||||||
18 | employment; supplemental security income; social security | ||||||
19 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
20 | National Practitioner Data Bank (NPDB); program and agency | ||||||
21 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
22 | corporate information; and death records. | ||||||
23 | The Illinois Department shall enter into agreements with | ||||||
24 | State agencies and departments, and is authorized to enter | ||||||
25 | into agreements with federal agencies and departments, under | ||||||
26 | which such agencies and departments shall share data necessary |
| |||||||
| |||||||
1 | for medical assistance program integrity functions and | ||||||
2 | oversight. The Illinois Department shall develop, in | ||||||
3 | cooperation with other State departments and agencies, and in | ||||||
4 | compliance with applicable federal laws and regulations, | ||||||
5 | appropriate and effective methods to share such data. At a | ||||||
6 | minimum, and to the extent necessary to provide data sharing, | ||||||
7 | the Illinois Department shall enter into agreements with State | ||||||
8 | agencies and departments, and is authorized to enter into | ||||||
9 | agreements with federal agencies and departments, including , | ||||||
10 | but not limited to: the Secretary of State; the Department of | ||||||
11 | Revenue; the Department of Public Health; the Department of | ||||||
12 | Human Services; and the Department of Financial and | ||||||
13 | Professional Regulation. | ||||||
14 | Beginning in fiscal year 2013, the Illinois Department | ||||||
15 | shall set forth a request for information to identify the | ||||||
16 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
17 | claims system with the goals of streamlining claims processing | ||||||
18 | and provider reimbursement, reducing the number of pending or | ||||||
19 | rejected claims, and helping to ensure a more transparent | ||||||
20 | adjudication process through the utilization of: (i) provider | ||||||
21 | data verification and provider screening technology; and (ii) | ||||||
22 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
23 | post-adjudicated predictive modeling with an integrated case | ||||||
24 | management system with link analysis. Such a request for | ||||||
25 | information shall not be considered as a request for proposal | ||||||
26 | or as an obligation on the part of the Illinois Department to |
| |||||||
| |||||||
1 | take any action or acquire any products or services. | ||||||
2 | The Illinois Department shall establish policies, | ||||||
3 | procedures,
standards and criteria by rule for the | ||||||
4 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
5 | devices and durable medical equipment. Such
rules shall | ||||||
6 | provide, but not be limited to, the following services: (1)
| ||||||
7 | immediate repair or replacement of such devices by recipients; | ||||||
8 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
9 | medical equipment in a cost-effective manner, taking into
| ||||||
10 | consideration the recipient's medical prognosis, the extent of | ||||||
11 | the
recipient's needs, and the requirements and costs for | ||||||
12 | maintaining such
equipment. Subject to prior approval, such | ||||||
13 | rules shall enable a recipient to temporarily acquire and
use | ||||||
14 | alternative or substitute devices or equipment pending repairs | ||||||
15 | or
replacements of any device or equipment previously | ||||||
16 | authorized for such
recipient by the Department. | ||||||
17 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
18 | the Department may, by rule, exempt certain replacement | ||||||
19 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
20 | wheelchair parts, wheelchair accessories, and related seating | ||||||
21 | and positioning items, determine the wholesale price by | ||||||
22 | methods other than actual acquisition costs. | ||||||
23 | The Department shall require, by rule, all providers of | ||||||
24 | durable medical equipment to be accredited by an accreditation | ||||||
25 | organization approved by the federal Centers for Medicare and | ||||||
26 | Medicaid Services and recognized by the Department in order to |
| |||||||
| |||||||
1 | bill the Department for providing durable medical equipment to | ||||||
2 | recipients. No later than 15 months after the effective date | ||||||
3 | of the rule adopted pursuant to this paragraph, all providers | ||||||
4 | must meet the accreditation requirement.
| ||||||
5 | In order to promote environmental responsibility, meet the | ||||||
6 | needs of recipients and enrollees, and achieve significant | ||||||
7 | cost savings, the Department, or a managed care organization | ||||||
8 | under contract with the Department, may provide recipients or | ||||||
9 | managed care enrollees who have a prescription or Certificate | ||||||
10 | of Medical Necessity access to refurbished durable medical | ||||||
11 | equipment under this Section (excluding prosthetic and | ||||||
12 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
13 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
14 | products and associated services) through the State's | ||||||
15 | assistive technology program's reutilization program, using | ||||||
16 | staff with the Assistive Technology Professional (ATP) | ||||||
17 | Certification if the refurbished durable medical equipment: | ||||||
18 | (i) is available; (ii) is less expensive, including shipping | ||||||
19 | costs, than new durable medical equipment of the same type; | ||||||
20 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
21 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
22 | federal Food and Drug Administration regulations and guidance | ||||||
23 | governing the reprocessing of medical devices in health care | ||||||
24 | settings; and (v) equally meets the needs of the recipient or | ||||||
25 | enrollee. The reutilization program shall confirm that the | ||||||
26 | recipient or enrollee is not already in receipt of same or |
| |||||||
| |||||||
1 | similar equipment from another service provider, and that the | ||||||
2 | refurbished durable medical equipment equally meets the needs | ||||||
3 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
4 | be construed to limit recipient or enrollee choice to obtain | ||||||
5 | new durable medical equipment or place any additional prior | ||||||
6 | authorization conditions on enrollees of managed care | ||||||
7 | organizations. | ||||||
8 | The Department shall execute, relative to the nursing home | ||||||
9 | prescreening
project, written inter-agency agreements with the | ||||||
10 | Department of Human
Services and the Department on Aging, to | ||||||
11 | effect the following: (i) intake
procedures and common | ||||||
12 | eligibility criteria for those persons who are receiving
| ||||||
13 | non-institutional services; and (ii) the establishment and | ||||||
14 | development of
non-institutional services in areas of the | ||||||
15 | State where they are not currently
available or are | ||||||
16 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
17 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
18 | increase in the determination of need (DON) scores from 29 to | ||||||
19 | 37 for applicants for institutional and home and | ||||||
20 | community-based long term care; if and only if federal | ||||||
21 | approval is not granted, the Department may, in conjunction | ||||||
22 | with other affected agencies, implement utilization controls | ||||||
23 | or changes in benefit packages to effectuate a similar savings | ||||||
24 | amount for this population; and (iv) no later than July 1, | ||||||
25 | 2013, minimum level of care eligibility criteria for | ||||||
26 | institutional and home and community-based long term care; and |
| |||||||
| |||||||
1 | (v) no later than October 1, 2013, establish procedures to | ||||||
2 | permit long term care providers access to eligibility scores | ||||||
3 | for individuals with an admission date who are seeking or | ||||||
4 | receiving services from the long term care provider. In order | ||||||
5 | to select the minimum level of care eligibility criteria, the | ||||||
6 | Governor shall establish a workgroup that includes affected | ||||||
7 | agency representatives and stakeholders representing the | ||||||
8 | institutional and home and community-based long term care | ||||||
9 | interests. This Section shall not restrict the Department from | ||||||
10 | implementing lower level of care eligibility criteria for | ||||||
11 | community-based services in circumstances where federal | ||||||
12 | approval has been granted.
| ||||||
13 | The Illinois Department shall develop and operate, in | ||||||
14 | cooperation
with other State Departments and agencies and in | ||||||
15 | compliance with
applicable federal laws and regulations, | ||||||
16 | appropriate and effective
systems of health care evaluation | ||||||
17 | and programs for monitoring of
utilization of health care | ||||||
18 | services and facilities, as it affects
persons eligible for | ||||||
19 | medical assistance under this Code.
| ||||||
20 | The Illinois Department shall report annually to the | ||||||
21 | General Assembly,
no later than the second Friday in April of | ||||||
22 | 1979 and each year
thereafter, in regard to:
| ||||||
23 | (a) actual statistics and trends in utilization of | ||||||
24 | medical services by
public aid recipients;
| ||||||
25 | (b) actual statistics and trends in the provision of | ||||||
26 | the various medical
services by medical vendors;
|
| |||||||
| |||||||
1 | (c) current rate structures and proposed changes in | ||||||
2 | those rate structures
for the various medical vendors; and
| ||||||
3 | (d) efforts at utilization review and control by the | ||||||
4 | Illinois Department.
| ||||||
5 | The period covered by each report shall be the 3 years | ||||||
6 | ending on the June
30 prior to the report. The report shall | ||||||
7 | include suggested legislation
for consideration by the General | ||||||
8 | Assembly. The requirement for reporting to the General | ||||||
9 | Assembly shall be satisfied
by filing copies of the report as | ||||||
10 | required by Section 3.1 of the General Assembly Organization | ||||||
11 | Act, and filing such additional
copies
with the State | ||||||
12 | Government Report Distribution Center for the General
Assembly | ||||||
13 | as is required under paragraph (t) of Section 7 of the State
| ||||||
14 | Library Act.
| ||||||
15 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
16 | any, is conditioned on the rules being adopted in accordance | ||||||
17 | with all provisions of the Illinois Administrative Procedure | ||||||
18 | Act and all rules and procedures of the Joint Committee on | ||||||
19 | Administrative Rules; any purported rule not so adopted, for | ||||||
20 | whatever reason, is unauthorized. | ||||||
21 | On and after July 1, 2012, the Department shall reduce any | ||||||
22 | rate of reimbursement for services or other payments or alter | ||||||
23 | any methodologies authorized by this Code to reduce any rate | ||||||
24 | of reimbursement for services or other payments in accordance | ||||||
25 | with Section 5-5e. | ||||||
26 | Because kidney transplantation can be an appropriate, |
| |||||||
| |||||||
1 | cost-effective
alternative to renal dialysis when medically | ||||||
2 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
3 | of this Code, beginning October 1, 2014, the Department shall | ||||||
4 | cover kidney transplantation for noncitizens with end-stage | ||||||
5 | renal disease who are not eligible for comprehensive medical | ||||||
6 | benefits, who meet the residency requirements of Section 5-3 | ||||||
7 | of this Code, and who would otherwise meet the financial | ||||||
8 | requirements of the appropriate class of eligible persons | ||||||
9 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
10 | kidney transplantation, such person must be receiving | ||||||
11 | emergency renal dialysis services covered by the Department. | ||||||
12 | Providers under this Section shall be prior approved and | ||||||
13 | certified by the Department to perform kidney transplantation | ||||||
14 | and the services under this Section shall be limited to | ||||||
15 | services associated with kidney transplantation. | ||||||
16 | Notwithstanding any other provision of this Code to the | ||||||
17 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
18 | medication assisted treatment prescribed for the treatment of | ||||||
19 | alcohol dependence or treatment of opioid dependence shall be | ||||||
20 | covered under both fee for service and managed care medical | ||||||
21 | assistance programs for persons who are otherwise eligible for | ||||||
22 | medical assistance under this Article and shall not be subject | ||||||
23 | to any (1) utilization control, other than those established | ||||||
24 | under the American Society of Addiction Medicine patient | ||||||
25 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
26 | lifetime restriction limit
mandate. |
| |||||||
| |||||||
1 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
2 | for the treatment of an opioid overdose, including the | ||||||
3 | medication product, administration devices, and any pharmacy | ||||||
4 | fees related to the dispensing and administration of the | ||||||
5 | opioid antagonist, shall be covered under the medical | ||||||
6 | assistance program for persons who are otherwise eligible for | ||||||
7 | medical assistance under this Article. As used in this | ||||||
8 | Section, "opioid antagonist" means a drug that binds to opioid | ||||||
9 | receptors and blocks or inhibits the effect of opioids acting | ||||||
10 | on those receptors, including, but not limited to, naloxone | ||||||
11 | hydrochloride or any other similarly acting drug approved by | ||||||
12 | the U.S. Food and Drug Administration. | ||||||
13 | Upon federal approval, the Department shall provide | ||||||
14 | coverage and reimbursement for all drugs that are approved for | ||||||
15 | marketing by the federal Food and Drug Administration and that | ||||||
16 | are recommended by the federal Public Health Service or the | ||||||
17 | United States Centers for Disease Control and Prevention for | ||||||
18 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
19 | services, including, but not limited to, HIV and sexually | ||||||
20 | transmitted infection screening, treatment for sexually | ||||||
21 | transmitted infections, medical monitoring, assorted labs, and | ||||||
22 | counseling to reduce the likelihood of HIV infection among | ||||||
23 | individuals who are not infected with HIV but who are at high | ||||||
24 | risk of HIV infection. | ||||||
25 | A federally qualified health center, as defined in Section | ||||||
26 | 1905(l)(2)(B) of the federal
Social Security Act, shall be |
| |||||||
| |||||||
1 | reimbursed by the Department in accordance with the federally | ||||||
2 | qualified health center's encounter rate for services provided | ||||||
3 | to medical assistance recipients that are performed by a | ||||||
4 | dental hygienist, as defined under the Illinois Dental | ||||||
5 | Practice Act, working under the general supervision of a | ||||||
6 | dentist and employed by a federally qualified health center. | ||||||
7 | Notwithstanding any other provision of this Code, | ||||||
8 | community-based pediatric palliative care from a trained | ||||||
9 | interdisciplinary team shall be covered under the medical | ||||||
10 | assistance program as provided in Section 15 of the Pediatric | ||||||
11 | Palliative
Care Act. | ||||||
12 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
13 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
14 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
15 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||||||
16 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | ||||||
17 | 1-1-20; revised 9-18-19.) | ||||||
18 | Section 5. The Pediatric Palliative Care Act is amended by | ||||||
19 | changing Sections 5, 10, 15, 20, 25, 30, 35, 40, and 45 and by | ||||||
20 | adding Section 37 as follows: | ||||||
21 | (305 ILCS 60/5)
| ||||||
22 | Sec. 5. Legislative findings. The General Assembly finds | ||||||
23 | as follows: | ||||||
24 | (1) Each year, approximately 1,500 1,185 Illinois |
| |||||||
| |||||||
1 | children are diagnosed with a serious illness potentially | ||||||
2 | life-limiting illness . | ||||||
3 | (2) There are many barriers to the provision of | ||||||
4 | pediatric palliative services, the most significant of | ||||||
5 | which include the following: (i) challenges in predicting | ||||||
6 | life expectancy; (ii) the reluctance of families and | ||||||
7 | professionals to acknowledge a child's incurable | ||||||
8 | condition; and (iii) the lack of an appropriate, | ||||||
9 | pediatric-focused reimbursement structure leading to | ||||||
10 | insufficient community-based resources. | ||||||
11 | (3) Community-based pediatric palliative services have | ||||||
12 | been shown to keep children out of the hospital by | ||||||
13 | managing many symptoms in the home setting, thereby | ||||||
14 | improving childhood quality of life while maintaining | ||||||
15 | budget neutrality. It is tremendously difficult for | ||||||
16 | physicians to prognosticate pediatric life expectancy due | ||||||
17 | to the resiliency of children. In addition, parents are | ||||||
18 | rarely prepared to cease curative efforts in order to | ||||||
19 | receive hospice or palliative care. Community-based | ||||||
20 | pediatric palliative services, however, keep children out | ||||||
21 | of the hospital by managing many symptoms in the home | ||||||
22 | setting, thereby improving childhood quality of life while | ||||||
23 | maintaining budget neutrality.
| ||||||
24 | (4) Pediatric palliative programming can, and should, | ||||||
25 | be administered in a cost neutral fashion. Community-based | ||||||
26 | pediatric palliative care allows for children and families |
| |||||||
| |||||||
1 | to receive pain and symptom management and psychosocial | ||||||
2 | support in the comfort of the home setting, thereby | ||||||
3 | avoiding excess spending for emergency room visits and | ||||||
4 | certain hospitals. The National Hospice and Palliative | ||||||
5 | Care Organization's pediatric task force reported during | ||||||
6 | 2001 that the average cost per child per year, cared for | ||||||
7 | primarily at home, receiving comprehensive palliative and | ||||||
8 | life prolonging services concurrently, is $16,177, | ||||||
9 | significantly less than the $19,000 to $48,000 per child | ||||||
10 | per year when palliative programs are not utilized.
| ||||||
11 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
12 | (305 ILCS 60/10)
| ||||||
13 | Sec. 10. Definitions Definition . In this Act : , | ||||||
14 | "Department" means the Department of Healthcare and Family | ||||||
15 | Services.
| ||||||
16 | "Palliative care" means care focused on expert assessment | ||||||
17 | and management of pain and other symptoms, assessment and | ||||||
18 | support of caregiver needs, and coordination of care. | ||||||
19 | Palliative care attends to the physical, functional, | ||||||
20 | psychological, practical, and spiritual consequences of a | ||||||
21 | serious illness. It is a person-centered and family-centered | ||||||
22 | approach to care, providing people living with serious illness | ||||||
23 | relief from the symptoms and stress of an illness. Through | ||||||
24 | early integration into the care plan for the seriously ill, | ||||||
25 | palliative care improves quality of life for the patient and |
| |||||||
| |||||||
1 | the family. Palliative care can be offered in all care | ||||||
2 | settings and at any stage in a serious illness through | ||||||
3 | collaboration of many types of care providers. | ||||||
4 | "Serious illness" means a health condition identified in | ||||||
5 | Section 25 that carries a high risk of mortality and | ||||||
6 | negatively impacts a person's daily function or quality of | ||||||
7 | life. | ||||||
8 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
9 | (305 ILCS 60/15)
| ||||||
10 | Sec. 15. Pediatric palliative care pilot program. The | ||||||
11 | Department shall develop a pediatric palliative care pilot | ||||||
12 | program , and the medical assistance program established under | ||||||
13 | Article V of the Illinois Public Aid Code shall cover under | ||||||
14 | which a qualifying child as defined in Section 25 may receive | ||||||
15 | community-based pediatric palliative care from a trained | ||||||
16 | interdisciplinary team , as an added benefit under which a | ||||||
17 | qualifying child, as defined in Section 25, may also choose to | ||||||
18 | continue while continuing to pursue aggressive curative or | ||||||
19 | disease-directed treatments for a serious potentially | ||||||
20 | life-limiting illness under the benefits available under | ||||||
21 | Article V of the Illinois Public Aid Code.
| ||||||
22 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
23 | (305 ILCS 60/20)
| ||||||
24 | Sec. 20. Federal waiver or State Plan amendment. If |
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| |||||||
1 | applicable, the The Department shall submit the necessary | ||||||
2 | application to the federal Centers for Medicare and Medicaid | ||||||
3 | Services for a waiver or State Plan amendment to implement the | ||||||
4 | pilot program described in this Act. If the application is in | ||||||
5 | the form of a State Plan amendment, the State Plan amendment | ||||||
6 | shall be filed prior to December 31, 2010. If the Department | ||||||
7 | does not submit a State Plan amendment prior to December 31, | ||||||
8 | 2010, the pilot program shall be created utilizing a waiver | ||||||
9 | authority. The waiver request shall be included in any | ||||||
10 | appropriate waiver application renewal submitted prior to | ||||||
11 | December 31, 2011, or shall be submitted as an independent | ||||||
12 | 1915(c) Home and Community Based Medicaid Waiver within that | ||||||
13 | same time period. After federal approval is secured, the | ||||||
14 | Department shall implement the waiver or State Plan amendment | ||||||
15 | within 12 months of the date of approval. The Department shall | ||||||
16 | not draft any rules in contravention of this timetable for | ||||||
17 | program development and implementation. By federal | ||||||
18 | requirement, the application for a 1915 (c) Medicaid waiver | ||||||
19 | program must demonstrate cost neutrality per the formula laid | ||||||
20 | out by the Centers for Medicare and Medicaid Services. The | ||||||
21 | Department shall not draft any rules in contravention of this | ||||||
22 | timetable for pilot program development and implementation. | ||||||
23 | This pilot program shall be implemented only to the extent | ||||||
24 | that federal financial participation is available.
| ||||||
25 | (Source: P.A. 96-1078, eff. 7-16-10.) |
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| |||||||
1 | (305 ILCS 60/25)
| ||||||
2 | Sec. 25. Qualifying child. | ||||||
3 | (a) For the purposes of this Act, a qualifying child is a | ||||||
4 | person under 21 18 years of age who is enrolled in the medical | ||||||
5 | assistance program under Article V of the Illinois Public Aid | ||||||
6 | Code and is diagnosed by the child's primary physician or | ||||||
7 | specialist as suffering from a serious illness and suffers | ||||||
8 | from a potentially life-limiting medical condition , as defined | ||||||
9 | in subsection (b). A child who is enrolled in the pilot program | ||||||
10 | prior to the age 18 may continue to receive services under the | ||||||
11 | pilot program until the day before his or her twenty-first | ||||||
12 | birthday.
| ||||||
13 | (b) The Department, in consultation with interested | ||||||
14 | stakeholders, shall determine the serious illnesses | ||||||
15 | potentially life-limiting medical conditions that render a | ||||||
16 | child who is enrolled in the pediatric medical assistance | ||||||
17 | program recipient eligible for the pilot program under this | ||||||
18 | Act. Such serious illnesses medical conditions shall include, | ||||||
19 | but need not be limited to, the following: | ||||||
20 | (1) Cancer (i) for which there is no known effective | ||||||
21 | treatment, (ii) that does not respond to conventional | ||||||
22 | protocol, (iii) that has progressed to an advanced stage, | ||||||
23 | or (iv) where toxicities or other complications limit | ||||||
24 | prohibit the administration of curative therapies. | ||||||
25 | (2) End-stage lung disease, including but not limited | ||||||
26 | to cystic fibrosis, that results in dependence on |
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| |||||||
1 | technology, such as mechanical ventilation. | ||||||
2 | (3) Severe neurological conditions, including, but not | ||||||
3 | limited to, hypoxic ischemic encephalopathy, acute brain | ||||||
4 | injury, brain infections and inflammatory diseases, or | ||||||
5 | irreversible severe alteration of mental status, with one | ||||||
6 | of the following co-morbidities: (i) intractable seizures | ||||||
7 | or (ii) brainstem failure to control breathing or other | ||||||
8 | automatic physiologic functions. | ||||||
9 | (4) Degenerative neuromuscular conditions, including, | ||||||
10 | but not limited to, spinal muscular atrophy, Type I or II, | ||||||
11 | or Duchenne Muscular Dystrophy, requiring technological | ||||||
12 | support. | ||||||
13 | (5) Genetic syndromes, such as , but not limited to, | ||||||
14 | Trisomy 13 or 18, where the child has substantial | ||||||
15 | neurocognitive disability (i) it is more likely than not | ||||||
16 | that the child will not live past 2 years of age or (ii) | ||||||
17 | the child is severely compromised with no expectation of | ||||||
18 | long-term survival. | ||||||
19 | (6) Congenital or acquired end-stage heart disease , | ||||||
20 | including but not limited to the following: (i) single | ||||||
21 | ventricle disorders, including hypoplastic left heart | ||||||
22 | syndrome; (ii) total anomalous pulmonary venous return, | ||||||
23 | not suitable for curative surgical treatment; and (iii) | ||||||
24 | heart muscle disorders (cardiomyopathies) without adequate | ||||||
25 | medical or surgical treatments available . | ||||||
26 | (7) End-stage liver disease where (i) transplant is |
| |||||||
| |||||||
1 | not a viable option or (ii) transplant rejection or | ||||||
2 | failure has occurred. | ||||||
3 | (8) End-stage kidney failure where (i) transplant is | ||||||
4 | not a viable option or (ii) transplant rejection or | ||||||
5 | failure has occurred. | ||||||
6 | (9) Metabolic or biochemical disorders, including, but | ||||||
7 | not limited to, mitochondrial disease, leukodystrophies, | ||||||
8 | Tay-Sachs disease, or Lesch-Nyhan syndrome where (i) no | ||||||
9 | suitable therapies exist or (ii) available treatments, | ||||||
10 | including stem cell ("bone marrow") transplant, have | ||||||
11 | failed. | ||||||
12 | (10) Congenital or acquired diseases of the | ||||||
13 | gastrointestinal system, such as "short bowel syndrome", | ||||||
14 | where (i) transplant is not a viable option or (ii) | ||||||
15 | transplant rejection or failure has occurred. | ||||||
16 | (11) Congenital skin disorders, including but not | ||||||
17 | limited to epidermolysis bullosa, where no suitable | ||||||
18 | treatment exists.
| ||||||
19 | (12) Any other serious illness that the Department, in | ||||||
20 | consultation with interested stakeholders, determines to | ||||||
21 | be appropriate. | ||||||
22 | The definition of a serious illness life-limiting medical | ||||||
23 | condition shall not include a definitive time period due to | ||||||
24 | the difficulty and challenges of prognosticating life | ||||||
25 | expectancy in children.
| ||||||
26 | (Source: P.A. 96-1078, eff. 7-16-10.) |
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| |||||||
1 | (305 ILCS 60/30)
| ||||||
2 | Sec. 30. Authorized providers. Providers authorized to | ||||||
3 | deliver services under the pilot waiver program shall include | ||||||
4 | licensed hospice agencies or home health agencies licensed to | ||||||
5 | provide hospice care or entities with demonstrated expertise | ||||||
6 | in pediatric palliative care and will be subject to further | ||||||
7 | criteria developed by the Department , in consultation with | ||||||
8 | interested stakeholders, for provider participation. At a | ||||||
9 | minimum, the participating provider must house a pediatric | ||||||
10 | interdisciplinary team that includes : (i) a physician, acting | ||||||
11 | as the program medical
director, who is board certified or | ||||||
12 | board eligible in pediatrics or hospice and palliative | ||||||
13 | medicine; (ii) a registered nurse; and (iii) a licensed social | ||||||
14 | worker with a background in pediatric care a pediatric medical | ||||||
15 | director, a nurse, and a licensed social worker . All members | ||||||
16 | of the pediatric interdisciplinary team must meet criteria the | ||||||
17 | Department may establish by rule, including demonstrated | ||||||
18 | expertise in pediatric palliative care. submit to the | ||||||
19 | Department proof of pediatric End-of-Life Nursing Education | ||||||
20 | Curriculum (Pediatric ELNEC Training) or an equivalent.
| ||||||
21 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
22 | (305 ILCS 60/35)
| ||||||
23 | Sec. 35. Interdisciplinary team; services. Subject to | ||||||
24 | federal approval for matching funds, the reimbursable services |
| |||||||
| |||||||
1 | offered under the pilot program shall be provided by an | ||||||
2 | interdisciplinary team, operating under the direction of a | ||||||
3 | program pediatric medical director, and shall include, but not | ||||||
4 | be limited to, the following: | ||||||
5 | (1) Nursing Pediatric nursing for pain and symptom | ||||||
6 | management. | ||||||
7 | (2) Expressive therapies ( such as music or and art | ||||||
8 | therapies) for age-appropriate counseling. | ||||||
9 | (3) Client and family counseling (provided by a | ||||||
10 | licensed social worker , licensed professional counselor, | ||||||
11 | child life specialist, or non-denominational chaplain or | ||||||
12 | spiritual counselor). | ||||||
13 | (4) Respite care. | ||||||
14 | (5) Bereavement services. | ||||||
15 | (6) Case management.
| ||||||
16 | (7) Any other services that the Department determines | ||||||
17 | to be appropriate. | ||||||
18 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
19 | (305 ILCS 60/37 new) | ||||||
20 | Sec. 37. Medical assistance program standards for | ||||||
21 | pediatric palliative care services. The Department, in | ||||||
22 | consultation with interested stakeholders, shall establish | ||||||
23 | standards for the provision of pediatric palliative care | ||||||
24 | services under the medical assistance program under Article V | ||||||
25 | of the Illinois Public Aid Code. The Department shall |
| |||||||
| |||||||
1 | establish standards for and provide technical assistance to | ||||||
2 | managed care organizations, as defined in Section 5-30.1 of | ||||||
3 | the Illinois Public Aid Code, to ensure the delivery of | ||||||
4 | pediatric palliative care services to qualifying children. | ||||||
5 | (305 ILCS 60/40)
| ||||||
6 | Sec. 40. Administration. | ||||||
7 | (a) The Department shall oversee the administration of the | ||||||
8 | pilot program. The Department, in consultation with interested | ||||||
9 | stakeholders, shall determine the appropriate process for | ||||||
10 | review of referrals and enrollment of qualifying children | ||||||
11 | participants . | ||||||
12 | (b) The Department shall appoint an individual or entity | ||||||
13 | to serve as program case manager or an alternative position to | ||||||
14 | assess level-of-care and target-population criteria for the | ||||||
15 | pilot program. The Department shall ensure that the individual | ||||||
16 | or entity meets the criteria for demonstrated expertise in | ||||||
17 | pediatric palliative care that the Department, in consultation | ||||||
18 | with interested stakeholders, may establish by rule receives | ||||||
19 | pediatric End-of-Life Nursing Education Curriculum (Pediatric | ||||||
20 | ELNEC Training) or an equivalent to become familiarized with | ||||||
21 | the unique needs and difficulties facing this population . The | ||||||
22 | process for review of referrals and enrollment of qualifying | ||||||
23 | children participants shall not include unnecessary delays and | ||||||
24 | shall reflect the fact that treatment of pain and other | ||||||
25 | distressing symptoms represents an urgent need for children |
| |||||||
| |||||||
1 | with a serious illness life-limiting medical conditions . The | ||||||
2 | process shall also acknowledge that children with a serious | ||||||
3 | illness life-limiting medical conditions and their families | ||||||
4 | require holistic and seamless care.
| ||||||
5 | (Source: P.A. 96-1078, eff. 7-16-10.) | ||||||
6 | (305 ILCS 60/45)
| ||||||
7 | Sec. 45. Report. Period of pilot program. After the | ||||||
8 | program has been in place for 3 years, the Department shall | ||||||
9 | prepare a report for the General Assembly concerning the | ||||||
10 | program's outcomes effectiveness and shall also make | ||||||
11 | recommendations for program improvement, including, but not | ||||||
12 | limited to, the appropriateness of those serious illnesses | ||||||
13 | that render a child who is enrolled in the medical assistance | ||||||
14 | program eligible for the program as defined in subsection (b) | ||||||
15 | of Section 25 and the necessary services needed to ensure | ||||||
16 | high-quality care for qualifying children and their families. | ||||||
17 | (a) The program implemented under this Act shall be | ||||||
18 | considered a pilot program for 3 years following the date of | ||||||
19 | program implementation or, if the pilot program is created | ||||||
20 | utilizing a waiver authority, until the waiver that includes | ||||||
21 | the services provided under the program undergoes the | ||||||
22 | federally mandated renewal process. | ||||||
23 | (b) During the period of time that the waiver program is | ||||||
24 | considered a pilot program, pediatric palliative care shall be | ||||||
25 | included in the issues reviewed by the Hospice and Palliative |
| |||||||
| |||||||
1 | Care Advisory Board. The Board shall make recommendations | ||||||
2 | regarding changes or improvements to the program, including | ||||||
3 | but not limited to advisement on potential expansion of the | ||||||
4 | potentially life-limiting medical conditions as defined in | ||||||
5 | subsection (b) of Section 25. | ||||||
6 | (c) At the end of the 3-year pilot program, the Department | ||||||
7 | shall prepare a report for the General Assembly concerning the | ||||||
8 | program's outcomes effectiveness and shall also make | ||||||
9 | recommendations for program improvement, including, but not | ||||||
10 | limited to, the appropriateness of the potentially | ||||||
11 | life-limiting medical conditions as defined in subsection (b) | ||||||
12 | of Section 25.
| ||||||
13 | (Source: P.A. 96-1078, eff. 7-16-10.)
| ||||||
14 | (305 ILCS 60/3 rep.) | ||||||
15 | Section 10. The Pediatric Palliative Care Act is amended | ||||||
16 | by repealing Section 3.".
|