HB1876 Enrolled LRB099 06677 KTG 26750 b
1		AN ACT concerning public aid.
2		Be it enacted by the People of the State of Illinois,
3		represented in the General Assembly:
4		Section 5. The Illinois Public Aid Code is amended by
5		changing Section 5-5 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 home,
16		or elsewhere; (6) medical care, or any other type of remedial
17		care furnished by licensed practitioners; (7) home health care
18		services; (8) private duty nursing service; (9) clinic
19		services; (10) dental services, including prevention and
20		treatment of periodontal disease and dental caries disease for
21		pregnant women, provided by an individual licensed to practice
22		dentistry or dental surgery; for purposes of this item (10),
23		"dental services" means diagnostic, preventive, or corrective

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1		procedures provided by or under the supervision of a dentist in
2		the practice of his or her profession; (11) physical therapy
3		and related services; (12) prescribed drugs, dentures, and
4		prosthetic devices; and eyeglasses prescribed by a physician
5		skilled in the diseases of the eye, or by an optometrist,
6		whichever the person may select; (13) other diagnostic,
7		screening, preventive, and rehabilitative services, including
8		to ensure that the individual's need for intervention or
9		treatment of mental disorders or substance use disorders or
10		co-occurring mental health and substance use disorders is
11		determined using a uniform screening, assessment, and
12		evaluation process inclusive of criteria, for children and
13		adults; for purposes of this item (13), a uniform screening,
14		assessment, and evaluation process refers to a process that
15		includes an appropriate evaluation and, as warranted, a
16		referral; "uniform" does not mean the use of a singular
17		instrument, tool, or process that all must utilize; (14)
18		transportation and such other expenses as may be necessary;
19		(15) medical treatment of sexual assault survivors, as defined
20		in Section 1a of the Sexual Assault Survivors Emergency
21		Treatment Act, for injuries sustained as a result of the sexual
22		assault, including examinations and laboratory tests to
23		discover evidence which may be used in criminal proceedings
24		arising from the sexual assault; (16) the diagnosis and
25		treatment of sickle cell anemia; and (17) any other medical
26		care, and any other type of remedial care recognized under the

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1		laws of this State, but not including abortions, or induced
2		miscarriages or premature births, unless, in the opinion of a
3		physician, such procedures are necessary for the preservation
4		of the life of the woman seeking such treatment, or except an
5		induced premature birth intended to produce a live viable child
6		and such procedure is necessary for the health of the mother or
7		her unborn child. The Illinois Department, by rule, shall
8		prohibit any physician from providing medical assistance to
9		anyone eligible therefor under this Code where such physician
10		has been found guilty of performing an abortion procedure in a
11		wilful and wanton manner upon a woman who was not pregnant at
12		the time such abortion procedure was performed. The term "any
13		other type of remedial care" shall include nursing care and
14		nursing home service for persons who rely on treatment by
15		spiritual means alone through prayer for healing.
16		Notwithstanding any other provision of this Section, a
17		comprehensive tobacco use cessation program that includes
18		purchasing prescription drugs or prescription medical devices
19		approved by the Food and Drug Administration shall be covered
20		under the medical assistance program under this Article for
21		persons who are otherwise eligible for assistance under this
22		Article.
23		Notwithstanding any other provision of this Code, the
24		Illinois Department may not require, as a condition of payment
25		for any laboratory test authorized under this Article, that a
26		physician's handwritten signature appear on the laboratory

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1		test order form. The Illinois Department may, however, impose
2		other appropriate requirements regarding laboratory test order
3		documentation.
4		Upon receipt of federal approval of an amendment to the
5		Illinois Title XIX State Plan for this purpose, the Department
6		shall authorize the Chicago Public Schools (CPS) to procure a
7		vendor or vendors to manufacture eyeglasses for individuals
8		enrolled in a school within the CPS system. CPS shall ensure
9		that its vendor or vendors are enrolled as providers in the
10		medical assistance program and in any capitated Medicaid
11		managed care entity (MCE) serving individuals enrolled in a
12		school within the CPS system. Under any contract procured under
13		this provision, the vendor or vendors must serve only
14		individuals enrolled in a school within the CPS system. Claims
15		for services provided by CPS's vendor or vendors to recipients
16		of benefits in the medical assistance program under this Code,
17		the Children's Health Insurance Program, or the Covering ALL
18		KIDS Health Insurance Program shall be submitted to the
19		Department or the MCE in which the individual is enrolled for
20		payment and shall be reimbursed at the Department's or the
21		MCE's established rates or rate methodologies for eyeglasses.
22		On and after July 1, 2012, the Department of Healthcare and
23		Family Services may provide the following services to persons
24		eligible for assistance under this Article who are
25		participating in education, training or employment programs
26		operated by the Department of Human Services as successor to

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1		the Department of Public Aid:
2		(1) dental services provided by or under the
3		supervision of a dentist; and
4		(2) eyeglasses prescribed by a physician skilled in the
5		diseases of the eye, or by an optometrist, whichever the
6		person may select.
7		Notwithstanding any other provision of this Code and
8		subject to federal approval, the Department may adopt rules to
9		allow a dentist who is volunteering his or her service at no
10		cost to render dental services through an enrolled
11		not-for-profit health clinic without the dentist personally
12		enrolling as a participating provider in the medical assistance
13		program. A not-for-profit health clinic shall include a public
14		health clinic or Federally Qualified Health Center or other
15		enrolled provider, as determined by the Department, through
16		which dental services covered under this Section are performed.
17		The Department shall establish a process for payment of claims
18		for reimbursement for covered dental services rendered under
19		this provision.
20		The Illinois Department, by rule, may distinguish and
21		classify the medical services to be provided only in accordance
22		with the classes of persons designated in Section 5-2.
23		The Department of Healthcare and Family Services must
24		provide coverage and reimbursement for amino acid-based
25		elemental formulas, regardless of delivery method, for the
26		diagnosis and treatment of (i) eosinophilic disorders and (ii)

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1		short bowel syndrome when the prescribing physician has issued
2		a written order stating that the amino acid-based elemental
3		formula is medically necessary.
4		The Illinois Department shall authorize the provision of,
5		and shall authorize payment for, screening by low-dose
6		mammography for the presence of occult breast cancer for women
7		35 years of age or older who are eligible for medical
8		assistance under this Article, as follows:
9		(A) A baseline mammogram for women 35 to 39 years of
10		age.
11		(B) An annual mammogram for women 40 years of age or
12		older.
13		(C) A mammogram at the age and intervals considered
14		medically necessary by the woman's health care provider for
15		women under 40 years of age and having a family history of
16		breast cancer, prior personal history of breast cancer,
17		positive genetic testing, or other risk factors.
18		(D) A comprehensive ultrasound screening of an entire
19		breast or breasts if a mammogram demonstrates
20		heterogeneous or dense breast tissue, when medically
21		necessary as determined by a physician licensed to practice
22		medicine in all of its branches.
23		All screenings shall include a physical breast exam,
24		instruction on self-examination and information regarding the
25		frequency of self-examination and its value as a preventative
26		tool. For purposes of this Section, "low-dose mammography"

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1		means the x-ray examination of the breast using equipment
2		dedicated specifically for mammography, including the x-ray
3		tube, filter, compression device, and image receptor, with an
4		average radiation exposure delivery of less than one rad per
5		breast for 2 views of an average size breast. The term also
6		includes digital mammography.
7		On and after January 1, 2012, providers participating in a
8		quality improvement program approved by the Department shall be
9		reimbursed for screening and diagnostic mammography at the same
10		rate as the Medicare program's rates, including the increased
11		reimbursement for digital mammography.
12		The Department shall convene an expert panel including
13		representatives of hospitals, free-standing mammography
14		facilities, and doctors, including radiologists, to establish
15		quality standards.
16		Subject to federal approval, the Department shall
17		establish a rate methodology for mammography at federally
18		qualified health centers and other encounter-rate clinics.
19		These clinics or centers may also collaborate with other
20		hospital-based mammography facilities.
21		The Department shall establish a methodology to remind
22		women who are age-appropriate for screening mammography, but
23		who have not received a mammogram within the previous 18
24		months, of the importance and benefit of screening mammography.
25		The Department shall establish a performance goal for
26		primary care providers with respect to their female patients

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1		over age 40 receiving an annual mammogram. This performance
2		goal shall be used to provide additional reimbursement in the
3		form of a quality performance bonus to primary care providers
4		who meet that goal.
5		The Department shall devise a means of case-managing or
6		patient navigation for beneficiaries diagnosed with breast
7		cancer. This program shall initially operate as a pilot program
8		in areas of the State with the highest incidence of mortality
9		related to breast cancer. At least one pilot program site shall
10		be in the metropolitan Chicago area and at least one site shall
11		be outside the metropolitan Chicago area. An evaluation of the
12		pilot program shall be carried out measuring health outcomes
13		and cost of care for those served by the pilot program compared
14		to similarly situated patients who are not served by the pilot
15		program.
16		Any medical or health care provider shall immediately
17		recommend, to any pregnant woman who is being provided prenatal
18		services and is suspected of drug abuse or is addicted as
19		defined in the Alcoholism and Other Drug Abuse and Dependency
20		Act, referral to a local substance abuse treatment provider
21		licensed by the Department of Human Services or to a licensed
22		hospital which provides substance abuse treatment services.
23		The Department of Healthcare and Family Services shall assure
24		coverage for the cost of treatment of the drug abuse or
25		addiction for pregnant recipients in accordance with the
26		Illinois Medicaid Program in conjunction with the Department of

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1		Human Services.
2		All medical providers providing medical assistance to
3		pregnant women under this Code shall receive information from
4		the Department on the availability of services under the Drug
5		Free Families with a Future or any comparable program providing
6		case management services for addicted women, including
7		information on appropriate referrals for other social services
8		that may be needed by addicted women in addition to treatment
9		for addiction.
10		The Illinois Department, in cooperation with the
11		Departments of Human Services (as successor to the Department
12		of Alcoholism and Substance Abuse) and Public Health, through a
13		public awareness campaign, may provide information concerning
14		treatment for alcoholism and drug abuse and addiction, prenatal
15		health care, and other pertinent programs directed at reducing
16		the number of drug-affected infants born to recipients of
17		medical assistance.
18		Neither the Department of Healthcare and Family Services
19		nor the Department of Human Services shall sanction the
20		recipient solely on the basis of her substance abuse.
21		The Illinois Department shall establish such regulations
22		governing the dispensing of health services under this Article
23		as it shall deem appropriate. The Department should seek the
24		advice of formal professional advisory committees appointed by
25		the Director of the Illinois Department for the purpose of
26		providing regular advice on policy and administrative matters,

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1		information dissemination and educational activities for
2		medical and health care providers, and consistency in
3		procedures to the Illinois Department.
4		The Illinois Department may develop and contract with
5		Partnerships of medical providers to arrange medical services
6		for persons eligible under Section 5-2 of this Code.
7		Implementation of this Section may be by demonstration projects
8		in certain geographic areas. The Partnership shall be
9		represented by a sponsor organization. The Department, by rule,
10		shall develop qualifications for sponsors of Partnerships.
11		Nothing in this Section shall be construed to require that the
12		sponsor organization be a medical organization.
13		The sponsor must negotiate formal written contracts with
14		medical providers for physician services, inpatient and
15		outpatient hospital care, home health services, treatment for
16		alcoholism and substance abuse, and other services determined
17		necessary by the Illinois Department by rule for delivery by
18		Partnerships. Physician services must include prenatal and
19		obstetrical care. The Illinois Department shall reimburse
20		medical services delivered by Partnership providers to clients
21		in target areas according to provisions of this Article and the
22		Illinois Health Finance Reform Act, except that:
23		(1) Physicians participating in a Partnership and
24		providing certain services, which shall be determined by
25		the Illinois Department, to persons in areas covered by the
26		Partnership may receive an additional surcharge for such

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1		services.
2		(2) The Department may elect to consider and negotiate
3		financial incentives to encourage the development of
4		Partnerships and the efficient delivery of medical care.
5		(3) Persons receiving medical services through
6		Partnerships may receive medical and case management
7		services above the level usually offered through the
8		medical assistance program.
9		Medical providers shall be required to meet certain
10		qualifications to participate in Partnerships to ensure the
11		delivery of high quality medical services. These
12		qualifications shall be determined by rule of the Illinois
13		Department and may be higher than qualifications for
14		participation in the medical assistance program. Partnership
15		sponsors may prescribe reasonable additional qualifications
16		for participation by medical providers, only with the prior
17		written approval of the Illinois Department.
18		Nothing in this Section shall limit the free choice of
19		practitioners, hospitals, and other providers of medical
20		services by clients. In order to ensure patient freedom of
21		choice, the Illinois Department shall immediately promulgate
22		all rules and take all other necessary actions so that provided
23		services may be accessed from therapeutically certified
24		optometrists to the full extent of the Illinois Optometric
25		Practice Act of 1987 without discriminating between service
26		providers.

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1		The Department shall apply for a waiver from the United
2		States Health Care Financing Administration to allow for the
3		implementation of Partnerships under this Section.
4		The Illinois Department shall require health care
5		providers to maintain records that document the medical care
6		and services provided to recipients of Medical Assistance under
7		this Article. Such records must be retained for a period of not
8		less than 6 years from the date of service or as provided by
9		applicable State law, whichever period is longer, except that
10		if an audit is initiated within the required retention period
11		then the records must be retained until the audit is completed
12		and every exception is resolved. The Illinois Department shall
13		require health care providers to make available, when
14		authorized by the patient, in writing, the medical records in a
15		timely fashion to other health care providers who are treating
16		or serving persons eligible for Medical Assistance under this
17		Article. All dispensers of medical services shall be required
18		to maintain and retain business and professional records
19		sufficient to fully and accurately document the nature, scope,
20		details and receipt of the health care provided to persons
21		eligible for medical assistance under this Code, in accordance
22		with regulations promulgated by the Illinois Department. The
23		rules and regulations shall require that proof of the receipt
24		of prescription drugs, dentures, prosthetic devices and
25		eyeglasses by eligible persons under this Section accompany
26		each claim for reimbursement submitted by the dispenser of such

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1		medical services. No such claims for reimbursement shall be
2		approved for payment by the Illinois Department without such
3		proof of receipt, unless the Illinois Department shall have put
4		into effect and shall be operating a system of post-payment
5		audit and review which shall, on a sampling basis, be deemed
6		adequate by the Illinois Department to assure that such drugs,
7		dentures, prosthetic devices and eyeglasses for which payment
8		is being made are actually being received by eligible
9		recipients. Within 90 days after the effective date of this
10		amendatory Act of 1984, the Illinois Department shall establish
11		a current list of acquisition costs for all prosthetic devices
12		and any other items recognized as medical equipment and
13		supplies reimbursable under this Article and shall update such
14		list on a quarterly basis, except that the acquisition costs of
15		all prescription drugs shall be updated no less frequently than
16		every 30 days as required by Section 5-5.12.
17		The rules and regulations of the Illinois Department shall
18		require that a written statement including the required opinion
19		of a physician shall accompany any claim for reimbursement for
20		abortions, or induced miscarriages or premature births. This
21		statement shall indicate what procedures were used in providing
22		such medical services.
23		Notwithstanding any other law to the contrary, the Illinois
24		Department shall, within 365 days after July 22, 2013, (the
25		effective date of Public Act 98-104), establish procedures to
26		permit skilled care facilities licensed under the Nursing Home

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1		Care Act to submit monthly billing claims for reimbursement
2		purposes. Following development of these procedures, the
3		Department shall, by July 1, 2016, have an additional 365 days
4		to test the viability of the new system and implement to ensure
5		that any necessary operational or structural changes to its
6		information technology platforms in order to allow for the
7		direct acceptance and payment of nursing home claims are
8		implemented.
9		Notwithstanding any other law to the contrary, the Illinois
10		Department shall, within 365 days after August 15, 2014 (the
11		effective date of Public Act 98-963) this amendatory Act of the
12		98th General Assembly, establish procedures to permit ID/DD
13		facilities licensed under the ID/DD Community Care Act to
14		submit monthly billing claims for reimbursement purposes.
15		Following development of these procedures, the Department
16		shall have an additional 365 days to test the viability of the
17		new system and to ensure that any necessary operational or
18		structural changes to its information technology platforms are
19		implemented.
20		The Illinois Department shall require all dispensers of
21		medical services, other than an individual practitioner or
22		group of practitioners, desiring to participate in the Medical
23		Assistance program established under this Article to disclose
24		all financial, beneficial, ownership, equity, surety or other
25		interests in any and all firms, corporations, partnerships,
26		associations, business enterprises, joint ventures, agencies,

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1		institutions or other legal entities providing any form of
2		health care services in this State under this Article.
3		The Illinois Department may require that all dispensers of
4		medical services desiring to participate in the medical
5		assistance program established under this Article disclose,
6		under such terms and conditions as the Illinois Department may
7		by rule establish, all inquiries from clients and attorneys
8		regarding medical bills paid by the Illinois Department, which
9		inquiries could indicate potential existence of claims or liens
10		for the Illinois Department.
11		Enrollment of a vendor shall be subject to a provisional
12		period and shall be conditional for one year. During the period
13		of conditional enrollment, the Department may terminate the
14		vendor's eligibility to participate in, or may disenroll the
15		vendor from, the medical assistance program without cause.
16		Unless otherwise specified, such termination of eligibility or
17		disenrollment is not subject to the Department's hearing
18		process. However, a disenrolled vendor may reapply without
19		penalty.
20		The Department has the discretion to limit the conditional
21		enrollment period for vendors based upon category of risk of
22		the vendor.
23		Prior to enrollment and during the conditional enrollment
24		period in the medical assistance program, all vendors shall be
25		subject to enhanced oversight, screening, and review based on
26		the risk of fraud, waste, and abuse that is posed by the

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1		category of risk of the vendor. The Illinois Department shall
2		establish the procedures for oversight, screening, and review,
3		which may include, but need not be limited to: criminal and
4		financial background checks; fingerprinting; license,
5		certification, and authorization verifications; unscheduled or
6		unannounced site visits; database checks; prepayment audit
7		reviews; audits; payment caps; payment suspensions; and other
8		screening as required by federal or State law.
9		The Department shall define or specify the following: (i)
10		by provider notice, the "category of risk of the vendor" for
11		each type of vendor, which shall take into account the level of
12		screening applicable to a particular category of vendor under
13		federal law and regulations; (ii) by rule or provider notice,
14		the maximum length of the conditional enrollment period for
15		each category of risk of the vendor; and (iii) by rule, the
16		hearing rights, if any, afforded to a vendor in each category
17		of risk of the vendor that is terminated or disenrolled during
18		the conditional enrollment period.
19		To be eligible for payment consideration, a vendor's
20		payment claim or bill, either as an initial claim or as a
21		resubmitted claim following prior rejection, must be received
22		by the Illinois Department, or its fiscal intermediary, no
23		later than 180 days after the latest date on the claim on which
24		medical goods or services were provided, with the following
25		exceptions:
26		(1) In the case of a provider whose enrollment is in

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1		process by the Illinois Department, the 180-day period
2		shall not begin until the date on the written notice from
3		the Illinois Department that the provider enrollment is
4		complete.
5		(2) In the case of errors attributable to the Illinois
6		Department or any of its claims processing intermediaries
7		which result in an inability to receive, process, or
8		adjudicate a claim, the 180-day period shall not begin
9		until the provider has been notified of the error.
10		(3) In the case of a provider for whom the Illinois
11		Department initiates the monthly billing process.
12		(4) In the case of a provider operated by a unit of
13		local government with a population exceeding 3,000,000
14		when local government funds finance federal participation
15		for claims payments.
16		For claims for services rendered during a period for which
17		a recipient received retroactive eligibility, claims must be
18		filed within 180 days after the Department determines the
19		applicant is eligible. For claims for which the Illinois
20		Department is not the primary payer, claims must be submitted
21		to the Illinois Department within 180 days after the final
22		adjudication by the primary payer.
23		In the case of long term care facilities, within 5 days of
24		receipt by the facility of required prescreening information,
25		data for new admissions shall be entered into the Medical
26		Electronic Data Interchange (MEDI) or the Recipient

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1		Eligibility Verification (REV) System or successor system, and
2		within 15 days of receipt by the facility of required
3		prescreening information, admission documents shall be
4		submitted through MEDI or REV or shall be submitted directly to
5		the Department of Human Services using required admission
6		forms. Effective September 1, 2014, admission documents,
7		including all prescreening information, must be submitted
8		through MEDI or REV. Confirmation numbers assigned to an
9		accepted transaction shall be retained by a facility to verify
10		timely submittal. Once an admission transaction has been
11		completed, all resubmitted claims following prior rejection
12		are subject to receipt no later than 180 days after the
13		admission transaction has been completed.
14		Claims that are not submitted and received in compliance
15		with the foregoing requirements shall not be eligible for
16		payment under the medical assistance program, and the State
17		shall have no liability for payment of those claims.
18		To the extent consistent with applicable information and
19		privacy, security, and disclosure laws, State and federal
20		agencies and departments shall provide the Illinois Department
21		access to confidential and other information and data necessary
22		to perform eligibility and payment verifications and other
23		Illinois Department functions. This includes, but is not
24		limited to: information pertaining to licensure;
25		certification; earnings; immigration status; citizenship; wage
26		reporting; unearned and earned income; pension income;

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1		employment; supplemental security income; social security
2		numbers; National Provider Identifier (NPI) numbers; the
3		National Practitioner Data Bank (NPDB); program and agency
4		exclusions; taxpayer identification numbers; tax delinquency;
5		corporate information; and death records.
6		The Illinois Department shall enter into agreements with
7		State agencies and departments, and is authorized to enter into
8		agreements with federal agencies and departments, under which
9		such agencies and departments shall share data necessary for
10		medical assistance program integrity functions and oversight.
11		The Illinois Department shall develop, in cooperation with
12		other State departments and agencies, and in compliance with
13		applicable federal laws and regulations, appropriate and
14		effective methods to share such data. At a minimum, and to the
15		extent necessary to provide data sharing, the Illinois
16		Department shall enter into agreements with State agencies and
17		departments, and is authorized to enter into agreements with
18		federal agencies and departments, including but not limited to:
19		the Secretary of State; the Department of Revenue; the
20		Department of Public Health; the Department of Human Services;
21		and the Department of Financial and Professional Regulation.
22		Beginning in fiscal year 2013, the Illinois Department
23		shall set forth a request for information to identify the
24		benefits of a pre-payment, post-adjudication, and post-edit
25		claims system with the goals of streamlining claims processing
26		and provider reimbursement, reducing the number of pending or

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1		rejected claims, and helping to ensure a more transparent
2		adjudication process through the utilization of: (i) provider
3		data verification and provider screening technology; and (ii)
4		clinical code editing; and (iii) pre-pay, pre- or
5		post-adjudicated predictive modeling with an integrated case
6		management system with link analysis. Such a request for
7		information shall not be considered as a request for proposal
8		or as an obligation on the part of the Illinois Department to
9		take any action or acquire any products or services.
10		The Illinois Department shall establish policies,
11		procedures, standards and criteria by rule for the acquisition,
12		repair and replacement of orthotic and prosthetic devices and
13		durable medical equipment. Such rules shall provide, but not be
14		limited to, the following services: (1) immediate repair or
15		replacement of such devices by recipients; and (2) rental,
16		lease, purchase or lease-purchase of durable medical equipment
17		in a cost-effective manner, taking into consideration the
18		recipient's medical prognosis, the extent of the recipient's
19		needs, and the requirements and costs for maintaining such
20		equipment. Subject to prior approval, such rules shall enable a
21		recipient to temporarily acquire and use alternative or
22		substitute devices or equipment pending repairs or
23		replacements of any device or equipment previously authorized
24		for such recipient by the Department.
25		The Department shall execute, relative to the nursing home
26		prescreening project, written inter-agency agreements with the

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1		Department of Human Services and the Department on Aging, to
2		effect the following: (i) intake procedures and common
3		eligibility criteria for those persons who are receiving
4		non-institutional services; and (ii) the establishment and
5		development of non-institutional services in areas of the State
6		where they are not currently available or are undeveloped; and
7		(iii) notwithstanding any other provision of law, subject to
8		federal approval, on and after July 1, 2012, an increase in the
9		determination of need (DON) scores from 29 to 37 for applicants
10		for institutional and home and community-based long term care;
11		if and only if federal approval is not granted, the Department
12		may, in conjunction with other affected agencies, implement
13		utilization controls or changes in benefit packages to
14		effectuate a similar savings amount for this population; and
15		(iv) no later than July 1, 2013, minimum level of care
16		eligibility criteria for institutional and home and
17		community-based long term care; and (v) no later than October
18		1, 2013, establish procedures to permit long term care
19		providers access to eligibility scores for individuals with an
20		admission date who are seeking or receiving services from the
21		long term care provider. In order to select the minimum level
22		of care eligibility criteria, the Governor shall establish a
23		workgroup that includes affected agency representatives and
24		stakeholders representing the institutional and home and
25		community-based long term care interests. This Section shall
26		not restrict the Department from implementing lower level of

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1		care eligibility criteria for community-based services in
2		circumstances where federal 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 and
7		programs for monitoring of utilization of health care services
8		and facilities, as it affects persons eligible for medical
9		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 filing of one copy of the report with the
25		Speaker, one copy with the Minority Leader and one copy with
26		the Clerk of the House of Representatives, one copy with the

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1		President, one copy with the Minority Leader and one copy with
2		the Secretary of the Senate, one copy with the Legislative
3		Research Unit, and such additional copies with the State
4		Government Report Distribution Center for the General Assembly
5		as is required under paragraph (t) of Section 7 of the State
6		Library Act shall be deemed sufficient to comply with this
7		Section.
8		Rulemaking authority to implement Public Act 95-1045, if
9		any, is conditioned on the rules being adopted in accordance
10		with all provisions of the Illinois Administrative Procedure
11		Act and all rules and procedures of the Joint Committee on
12		Administrative Rules; any purported rule not so adopted, for
13		whatever reason, is unauthorized.
14		On and after July 1, 2012, the Department shall reduce any
15		rate of reimbursement for services or other payments or alter
16		any methodologies authorized by this Code to reduce any rate of
17		reimbursement for services or other payments in accordance with
18		Section 5-5e.
19		Because kidney transplantation can be an appropriate, cost
20		effective alternative to renal dialysis when medically
21		necessary and notwithstanding the provisions of Section 1-11 of
22		this Code, beginning October 1, 2014, the Department shall
23		cover kidney transplantation for noncitizens with end-stage
24		renal disease who are not eligible for comprehensive medical
25		benefits, who meet the residency requirements of Section 5-3 of
26		this Code, and who would otherwise meet the financial

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1		requirements of the appropriate class of eligible persons under
2		Section 5-2 of this Code. To qualify for coverage of kidney
3		transplantation, such person must be receiving emergency renal
4		dialysis services covered by the Department. Providers under
5		this Section shall be prior approved and certified by the
6		Department to perform kidney transplantation and the services
7		under this Section shall be limited to services associated with
8		kidney transplantation.
9		(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
10		eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
11		9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
12		7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
13		eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
14		revised 10-2-14.)