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Illinois General Assembly - Full Text of HB5313

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Full Text of HB5313

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HB5313 - 104th General Assembly

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HB5313 Engrossed
LRB104 20195 KTG 33646 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 5-5f as follows:

6

(305 ILCS 5/5-5f)
7

Sec. 5-5f.
Elimination and limitations of medical
8
assistance services.
Notwithstanding any other provision of
9
this Code to the contrary, on and after July 1, 2012:
10

(a) The following service shall no longer be a covered
11

service available under this Code: group psychotherapy for
12

residents of any facility licensed under the Nursing Home
13

Care Act or the Specialized Mental Health Rehabilitation
14

Act of 2013.
15

(b) The Department shall place the following
16

limitations on services: (i) the Department shall limit
17

adult eyeglasses to one pair every 2 years; however, the
18

limitation does not apply to an individual who needs
19

different eyeglasses following a surgical procedure such
20

as cataract surgery; (ii) the Department shall set an
21

annual limit of a maximum of 20 visits for each of the
22

following services: adult speech, hearing, and language
23

therapy services, adult occupational therapy services, and

HB5313 Engrossed
- 2 -
LRB104 20195 KTG 33646 b
1

physical therapy services; on or after October 1, 2014,
2

the annual maximum limit of 20 visits shall expire but the
3

Department may require prior approval for all individuals
4

for speech, hearing, and language therapy services,
5

occupational therapy services, and physical therapy
6

services; (iii) the Department shall limit adult podiatry
7

services to individuals with diabetes; on or after October
8

1, 2014, podiatry services shall not be limited to
9

individuals with diabetes; (iv) the Department shall pay
10

for caesarean sections at the normal vaginal delivery rate
11

unless a caesarean section was medically necessary; (v)
12

the Department shall limit adult dental services to
13

emergencies; beginning July 1, 2013, the Department shall
14

ensure that the following conditions are recognized as
15

emergencies: (A) dental services necessary for an
16

individual in order for the individual to be cleared for a
17

medical procedure, such as a transplant; (B) extractions
18

and dentures necessary for a diabetic to receive proper
19

nutrition; (C) extractions and dentures necessary as a
20

result of cancer treatment; and (D) dental services
21

necessary for the health of a pregnant woman prior to
22

delivery of her baby; on or after July 1, 2014, adult
23

dental services shall no longer be limited to emergencies,
24

and dental services necessary for the health of a pregnant
25

woman prior to delivery of her baby shall continue to be
26

covered; and (vi) effective July 1, 2012 through June 30,

HB5313 Engrossed
- 3 -
LRB104 20195 KTG 33646 b
1

2021, the Department shall place limitations and require
2

concurrent review on every inpatient detoxification stay
3

to prevent repeat admissions to any hospital for
4

detoxification within 60 days of a previous inpatient
5

detoxification stay. The Department shall convene a
6

workgroup of hospitals, substance abuse providers, care
7

coordination entities, managed care plans, and other
8

stakeholders to develop recommendations for quality
9

standards, diversion to other settings, and admission
10

criteria for patients who need inpatient detoxification,
11

which shall be published on the Department's website no
12

later than September 1, 2013.
13

(c) The Department shall require prior approval of the
14

following services: wheelchair repairs costing more than
15

$750, coronary artery bypass graft, and bariatric surgery
16

consistent with Medicare standards concerning patient
17

responsibility. Wheelchair repair prior approval requests
18

shall be adjudicated within one business day of receipt of
19

complete supporting documentation. Providers may not break
20

wheelchair repairs into separate claims for purposes of
21

staying under the $750 threshold for requiring prior
22

approval. The wholesale price of manual and power
23

wheelchairs, durable medical equipment and supplies, and
24

complex rehabilitation technology products and services
25

shall be defined as actual acquisition cost including all
26

discounts.

HB5313 Engrossed
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LRB104 20195 KTG 33646 b
1

(d)
(Blank).

The Department shall establish benchmarks
2

for hospitals to measure and align payments to reduce
3

potentially preventable hospital readmissions, inpatient
4

complications, and unnecessary emergency room visits. In
5

doing so, the Department shall consider items, including,
6

but not limited to, historic and current acuity of care
7

and historic and current trends in readmission. The
8

Department shall publish provider-specific historical
9

readmission data and anticipated potentially preventable
10

targets 60 days prior to the start of the program. In the
11

instance of readmissions, the Department shall adopt
12

policies and rates of reimbursement for services and other
13

payments provided under this Code to ensure that, by June
14

30, 2013, expenditures to hospitals are reduced by, at a
15

minimum, $40,000,000.

16

(e) The Department shall establish utilization
17

controls for the hospice program such that it shall not
18

pay for other care services when an individual is in
19

hospice.
20

(f) For home health services, the Department shall
21

require Medicare certification of providers participating
22

in the program and implement the Medicare face-to-face
23

encounter rule. The Department shall require providers to
24

implement auditable electronic service verification based
25

on global positioning systems or other cost-effective
26

technology.

HB5313 Engrossed
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LRB104 20195 KTG 33646 b
1

(g) For the Home Services Program operated by the
2

Department of Human Services and the Community Care
3

Program operated by the Department on Aging, the
4

Department of Human Services, in cooperation with the
5

Department on Aging, shall implement an electronic service
6

verification based on global positioning systems or other
7

cost-effective technology.
8

(h) Effective with inpatient hospital admissions on or
9

after July 1, 2012, the Department shall reduce the
10

payment for a claim that indicates the occurrence of a
11

provider-preventable condition during the admission as
12

specified by the Department in rules. The Department shall
13

not pay for services related to an other
14

provider-preventable condition.
15

As used in this subsection (h):
16

"Provider-preventable condition" means a health care
17

acquired condition as defined under the federal Medicaid
18

regulation found at 42 CFR 447.26 or an other
19

provider-preventable condition.
20

"Other provider-preventable condition" means a wrong
21

surgical or other invasive procedure performed on a
22

patient, a surgical or other invasive procedure performed
23

on the wrong body part, or a surgical procedure or other
24

invasive procedure performed on the wrong patient.
25

(i) The Department shall implement cost savings
26

initiatives for advanced imaging services, cardiac imaging

HB5313 Engrossed
- 6 -
LRB104 20195 KTG 33646 b
1

services, pain management services, and back surgery. Such
2

initiatives shall be designed to achieve annual costs
3

savings.
4

(j) The Department shall ensure that beneficiaries
5

with a diagnosis of epilepsy or seizure disorder in
6

Department records will not require prior approval for
7

anticonvulsants.
8
(Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section
9
5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff.
10
7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21;
11
102-813, eff. 5-13-22.)

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