103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, to address maternal mental health conditions and reduce the incidence of maternal mortality and morbidity and postpartum depression, pregnant women eligible to receive medical assistance shall receive coverage for prenatal and postnatal support services during pregnancy and during the 5-year period beginning on the last day of the pregnancy. Provides that prenatal and postnatal support services covered under the medical assistance program include, but are not limited to, services provided by doulas, lactation counselors, labor assistants, childbirth educators, community mental health centers or behavioral clinics, social workers, and public health nurses as well as any other evidence-based mental health and social care services that are designed to screen, identify, and manage maternal mental disorders. Permits the Department of Healthcare and Family Services to consult with the Department of Human Services and the Department of Public Health to establish a program of services consistent with the purposes of the amendatory Act. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment required to implement the provisions of the amendatory Act. Requires the Department to adopt rules, upon federal approval, on certification or licensing requirements for providers of prenatal and postnatal support services and rules to provide medical assistance reimbursement for such services. LRB103 04705 KTG 49714 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, to address maternal mental health conditions and reduce the incidence of maternal mortality and morbidity and postpartum depression, pregnant women eligible to receive medical assistance shall receive coverage for prenatal and postnatal support services during pregnancy and during the 5-year period beginning on the last day of the pregnancy. Provides that prenatal and postnatal support services covered under the medical assistance program include, but are not limited to, services provided by doulas, lactation counselors, labor assistants, childbirth educators, community mental health centers or behavioral clinics, social workers, and public health nurses as well as any other evidence-based mental health and social care services that are designed to screen, identify, and manage maternal mental disorders. Permits the Department of Healthcare and Family Services to consult with the Department of Human Services and the Department of Public Health to establish a program of services consistent with the purposes of the amendatory Act. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment required to implement the provisions of the amendatory Act. Requires the Department to adopt rules, upon federal approval, on certification or licensing requirements for providers of prenatal and postnatal support services and rules to provide medical assistance reimbursement for such services. LRB103 04705 KTG 49714 b LRB103 04705 KTG 49714 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, to address maternal mental health conditions and reduce the incidence of maternal mortality and morbidity and postpartum depression, pregnant women eligible to receive medical assistance shall receive coverage for prenatal and postnatal support services during pregnancy and during the 5-year period beginning on the last day of the pregnancy. Provides that prenatal and postnatal support services covered under the medical assistance program include, but are not limited to, services provided by doulas, lactation counselors, labor assistants, childbirth educators, community mental health centers or behavioral clinics, social workers, and public health nurses as well as any other evidence-based mental health and social care services that are designed to screen, identify, and manage maternal mental disorders. Permits the Department of Healthcare and Family Services to consult with the Department of Human Services and the Department of Public Health to establish a program of services consistent with the purposes of the amendatory Act. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment required to implement the provisions of the amendatory Act. Requires the Department to adopt rules, upon federal approval, on certification or licensing requirements for providers of prenatal and postnatal support services and rules to provide medical assistance reimbursement for such services. LRB103 04705 KTG 49714 b LRB103 04705 KTG 49714 b LRB103 04705 KTG 49714 b A BILL FOR HB1031LRB103 04705 KTG 49714 b HB1031 LRB103 04705 KTG 49714 b HB1031 LRB103 04705 KTG 49714 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 (Text of Section after amendment by P.A. 102-1018 and P.A. 8 102-1038) 9 Sec. 5-5. Medical services. The Illinois Department, by 10 rule, shall determine the quantity and quality of and the rate 11 of reimbursement for the medical assistance for which payment 12 will be authorized, and the medical services to be provided, 13 which may include all or part of the following: (1) inpatient 14 hospital services; (2) outpatient hospital services; (3) other 15 laboratory and X-ray services; (4) skilled nursing home 16 services; (5) physicians' services whether furnished in the 17 office, the patient's home, a hospital, a skilled nursing 18 home, or elsewhere; (6) medical care, or any other type of 19 remedial care furnished by licensed practitioners; (7) home 20 health care services; (8) private duty nursing service; (9) 21 clinic services; (10) dental services, including prevention 22 and treatment of periodontal disease and dental caries disease 23 for pregnant individuals, provided by an individual licensed 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, to address maternal mental health conditions and reduce the incidence of maternal mortality and morbidity and postpartum depression, pregnant women eligible to receive medical assistance shall receive coverage for prenatal and postnatal support services during pregnancy and during the 5-year period beginning on the last day of the pregnancy. Provides that prenatal and postnatal support services covered under the medical assistance program include, but are not limited to, services provided by doulas, lactation counselors, labor assistants, childbirth educators, community mental health centers or behavioral clinics, social workers, and public health nurses as well as any other evidence-based mental health and social care services that are designed to screen, identify, and manage maternal mental disorders. Permits the Department of Healthcare and Family Services to consult with the Department of Human Services and the Department of Public Health to establish a program of services consistent with the purposes of the amendatory Act. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment required to implement the provisions of the amendatory Act. Requires the Department to adopt rules, upon federal approval, on certification or licensing requirements for providers of prenatal and postnatal support services and rules to provide medical assistance reimbursement for such services. LRB103 04705 KTG 49714 b LRB103 04705 KTG 49714 b LRB103 04705 KTG 49714 b A BILL FOR 305 ILCS 5/5-5 from Ch. 23, par. 5-5 LRB103 04705 KTG 49714 b HB1031 LRB103 04705 KTG 49714 b HB1031- 2 -LRB103 04705 KTG 49714 b HB1031 - 2 - LRB103 04705 KTG 49714 b HB1031 - 2 - LRB103 04705 KTG 49714 b 1 to practice dentistry or dental surgery; for purposes of this 2 item (10), "dental services" means diagnostic, preventive, or 3 corrective procedures provided by or under the supervision of 4 a dentist in the practice of his or her profession; (11) 5 physical therapy and related services; (12) prescribed drugs, 6 dentures, and prosthetic devices; and eyeglasses prescribed by 7 a physician skilled in the diseases of the eye, or by an 8 optometrist, whichever the person may select; (13) other 9 diagnostic, screening, preventive, and rehabilitative 10 services, including to ensure that the individual's need for 11 intervention or treatment of mental disorders or substance use 12 disorders or co-occurring mental health and substance use 13 disorders is determined using a uniform screening, assessment, 14 and evaluation process inclusive of criteria, for children and 15 adults; for purposes of this item (13), a uniform screening, 16 assessment, and evaluation process refers to a process that 17 includes an appropriate evaluation and, as warranted, a 18 referral; "uniform" does not mean the use of a singular 19 instrument, tool, or process that all must utilize; (14) 20 transportation and such other expenses as may be necessary; 21 (15) medical treatment of sexual assault survivors, as defined 22 in Section 1a of the Sexual Assault Survivors Emergency 23 Treatment Act, for injuries sustained as a result of the 24 sexual assault, including examinations and laboratory tests to 25 discover evidence which may be used in criminal proceedings 26 arising from the sexual assault; (16) the diagnosis and HB1031 - 2 - LRB103 04705 KTG 49714 b HB1031- 3 -LRB103 04705 KTG 49714 b HB1031 - 3 - LRB103 04705 KTG 49714 b HB1031 - 3 - LRB103 04705 KTG 49714 b 1 treatment of sickle cell anemia; (16.5) services performed by 2 a chiropractic physician licensed under the Medical Practice 3 Act of 1987 and acting within the scope of his or her license, 4 including, but not limited to, chiropractic manipulative 5 treatment; and (17) any other medical care, and any other type 6 of remedial care recognized under the laws of this State. The 7 term "any other type of remedial care" shall include nursing 8 care and nursing home service for persons who rely on 9 treatment by spiritual means alone through prayer for healing. 10 Notwithstanding any other provision of this Section, a 11 comprehensive tobacco use cessation program that includes 12 purchasing prescription drugs or prescription medical devices 13 approved by the Food and Drug Administration shall be covered 14 under the medical assistance program under this Article for 15 persons who are otherwise eligible for assistance under this 16 Article. 17 Notwithstanding any other provision of this Code, 18 reproductive health care that is otherwise legal in Illinois 19 shall be covered under the medical assistance program for 20 persons who are otherwise eligible for medical assistance 21 under this Article. 22 Notwithstanding any other provision of this Section, all 23 tobacco cessation medications approved by the United States 24 Food and Drug Administration and all individual and group 25 tobacco cessation counseling services and telephone-based 26 counseling services and tobacco cessation medications provided HB1031 - 3 - LRB103 04705 KTG 49714 b HB1031- 4 -LRB103 04705 KTG 49714 b HB1031 - 4 - LRB103 04705 KTG 49714 b HB1031 - 4 - LRB103 04705 KTG 49714 b 1 through the Illinois Tobacco Quitline shall be covered under 2 the medical assistance program for persons who are otherwise 3 eligible for assistance under this Article. The Department 4 shall comply with all federal requirements necessary to obtain 5 federal financial participation, as specified in 42 CFR 6 433.15(b)(7), for telephone-based counseling services provided 7 through the Illinois Tobacco Quitline, including, but not 8 limited to: (i) entering into a memorandum of understanding or 9 interagency agreement with the Department of Public Health, as 10 administrator of the Illinois Tobacco Quitline; and (ii) 11 developing a cost allocation plan for Medicaid-allowable 12 Illinois Tobacco Quitline services in accordance with 45 CFR 13 95.507. The Department shall submit the memorandum of 14 understanding or interagency agreement, the cost allocation 15 plan, and all other necessary documentation to the Centers for 16 Medicare and Medicaid Services for review and approval. 17 Coverage under this paragraph shall be contingent upon federal 18 approval. 19 Notwithstanding any other provision of this Code, the 20 Illinois Department may not require, as a condition of payment 21 for any laboratory test authorized under this Article, that a 22 physician's handwritten signature appear on the laboratory 23 test order form. The Illinois Department may, however, impose 24 other appropriate requirements regarding laboratory test order 25 documentation. 26 Upon receipt of federal approval of an amendment to the HB1031 - 4 - LRB103 04705 KTG 49714 b HB1031- 5 -LRB103 04705 KTG 49714 b HB1031 - 5 - LRB103 04705 KTG 49714 b HB1031 - 5 - LRB103 04705 KTG 49714 b 1 Illinois Title XIX State Plan for this purpose, the Department 2 shall authorize the Chicago Public Schools (CPS) to procure a 3 vendor or vendors to manufacture eyeglasses for individuals 4 enrolled in a school within the CPS system. CPS shall ensure 5 that its vendor or vendors are enrolled as providers in the 6 medical assistance program and in any capitated Medicaid 7 managed care entity (MCE) serving individuals enrolled in a 8 school within the CPS system. Under any contract procured 9 under this provision, the vendor or vendors must serve only 10 individuals enrolled in a school within the CPS system. Claims 11 for services provided by CPS's vendor or vendors to recipients 12 of benefits in the medical assistance program under this Code, 13 the Children's Health Insurance Program, or the Covering ALL 14 KIDS Health Insurance Program shall be submitted to the 15 Department or the MCE in which the individual is enrolled for 16 payment and shall be reimbursed at the Department's or the 17 MCE's established rates or rate methodologies for eyeglasses. 18 On and after July 1, 2012, the Department of Healthcare 19 and Family Services may provide the following services to 20 persons eligible for assistance under this Article who are 21 participating in education, training or employment programs 22 operated by the Department of Human Services as successor to 23 the Department of Public Aid: 24 (1) dental services provided by or under the 25 supervision of a dentist; and 26 (2) eyeglasses prescribed by a physician skilled in HB1031 - 5 - LRB103 04705 KTG 49714 b HB1031- 6 -LRB103 04705 KTG 49714 b HB1031 - 6 - LRB103 04705 KTG 49714 b HB1031 - 6 - LRB103 04705 KTG 49714 b 1 the diseases of the eye, or by an optometrist, whichever 2 the person may select. 3 On and after July 1, 2018, the Department of Healthcare 4 and Family Services shall provide dental services to any adult 5 who is otherwise eligible for assistance under the medical 6 assistance program. As used in this paragraph, "dental 7 services" means diagnostic, preventative, restorative, or 8 corrective procedures, including procedures and services for 9 the prevention and treatment of periodontal disease and dental 10 caries disease, provided by an individual who is licensed to 11 practice dentistry or dental surgery or who is under the 12 supervision of a dentist in the practice of his or her 13 profession. 14 On and after July 1, 2018, targeted dental services, as 15 set forth in Exhibit D of the Consent Decree entered by the 16 United States District Court for the Northern District of 17 Illinois, Eastern Division, in the matter of Memisovski v. 18 Maram, Case No. 92 C 1982, that are provided to adults under 19 the medical assistance program shall be established at no less 20 than the rates set forth in the "New Rate" column in Exhibit D 21 of the Consent Decree for targeted dental services that are 22 provided to persons under the age of 18 under the medical 23 assistance program. 24 Notwithstanding any other provision of this Code and 25 subject to federal approval, the Department may adopt rules to 26 allow a dentist who is volunteering his or her service at no HB1031 - 6 - LRB103 04705 KTG 49714 b HB1031- 7 -LRB103 04705 KTG 49714 b HB1031 - 7 - LRB103 04705 KTG 49714 b HB1031 - 7 - LRB103 04705 KTG 49714 b 1 cost to render dental services through an enrolled 2 not-for-profit health clinic without the dentist personally 3 enrolling as a participating provider in the medical 4 assistance program. A not-for-profit health clinic shall 5 include a public health clinic or Federally Qualified Health 6 Center or other enrolled provider, as determined by the 7 Department, through which dental services covered under this 8 Section are performed. The Department shall establish a 9 process for payment of claims for reimbursement for covered 10 dental services rendered under this provision. 11 On and after January 1, 2022, the Department of Healthcare 12 and Family Services shall administer and regulate a 13 school-based dental program that allows for the out-of-office 14 delivery of preventative dental services in a school setting 15 to children under 19 years of age. The Department shall 16 establish, by rule, guidelines for participation by providers 17 and set requirements for follow-up referral care based on the 18 requirements established in the Dental Office Reference Manual 19 published by the Department that establishes the requirements 20 for dentists participating in the All Kids Dental School 21 Program. Every effort shall be made by the Department when 22 developing the program requirements to consider the different 23 geographic differences of both urban and rural areas of the 24 State for initial treatment and necessary follow-up care. No 25 provider shall be charged a fee by any unit of local government 26 to participate in the school-based dental program administered HB1031 - 7 - LRB103 04705 KTG 49714 b HB1031- 8 -LRB103 04705 KTG 49714 b HB1031 - 8 - LRB103 04705 KTG 49714 b HB1031 - 8 - LRB103 04705 KTG 49714 b 1 by the Department. Nothing in this paragraph shall be 2 construed to limit or preempt a home rule unit's or school 3 district's authority to establish, change, or administer a 4 school-based dental program in addition to, or independent of, 5 the school-based dental program administered by the 6 Department. 7 The Illinois Department, by rule, may distinguish and 8 classify the medical services to be provided only in 9 accordance with the classes of persons designated in Section 10 5-2. 11 The Department of Healthcare and Family Services must 12 provide coverage and reimbursement for amino acid-based 13 elemental formulas, regardless of delivery method, for the 14 diagnosis and treatment of (i) eosinophilic disorders and (ii) 15 short bowel syndrome when the prescribing physician has issued 16 a written order stating that the amino acid-based elemental 17 formula is medically necessary. 18 The Illinois Department shall authorize the provision of, 19 and shall authorize payment for, screening by low-dose 20 mammography for the presence of occult breast cancer for 21 individuals 35 years of age or older who are eligible for 22 medical assistance under this Article, as follows: 23 (A) A baseline mammogram for individuals 35 to 39 24 years of age. 25 (B) An annual mammogram for individuals 40 years of 26 age or older. HB1031 - 8 - LRB103 04705 KTG 49714 b HB1031- 9 -LRB103 04705 KTG 49714 b HB1031 - 9 - LRB103 04705 KTG 49714 b HB1031 - 9 - LRB103 04705 KTG 49714 b 1 (C) A mammogram at the age and intervals considered 2 medically necessary by the individual's health care 3 provider for individuals under 40 years of age and having 4 a family history of breast cancer, prior personal history 5 of breast cancer, positive genetic testing, or other risk 6 factors. 7 (D) A comprehensive ultrasound screening and MRI of an 8 entire breast or breasts if a mammogram demonstrates 9 heterogeneous or dense breast tissue or when medically 10 necessary as determined by a physician licensed to 11 practice medicine in all of its branches. 12 (E) A screening MRI when medically necessary, as 13 determined by a physician licensed to practice medicine in 14 all of its branches. 15 (F) A diagnostic mammogram when medically necessary, 16 as determined by a physician licensed to practice medicine 17 in all its branches, advanced practice registered nurse, 18 or physician assistant. 19 The Department shall not impose a deductible, coinsurance, 20 copayment, or any other cost-sharing requirement on the 21 coverage provided under this paragraph; except that this 22 sentence does not apply to coverage of diagnostic mammograms 23 to the extent such coverage would disqualify a high-deductible 24 health plan from eligibility for a health savings account 25 pursuant to Section 223 of the Internal Revenue Code (26 26 U.S.C. 223). HB1031 - 9 - LRB103 04705 KTG 49714 b HB1031- 10 -LRB103 04705 KTG 49714 b HB1031 - 10 - LRB103 04705 KTG 49714 b HB1031 - 10 - LRB103 04705 KTG 49714 b 1 All screenings shall include a physical breast exam, 2 instruction on self-examination and information regarding the 3 frequency of self-examination and its value as a preventative 4 tool. 5 For purposes of this Section: 6 "Diagnostic mammogram" means a mammogram obtained using 7 diagnostic mammography. 8 "Diagnostic mammography" means a method of screening that 9 is designed to evaluate an abnormality in a breast, including 10 an abnormality seen or suspected on a screening mammogram or a 11 subjective or objective abnormality otherwise detected in the 12 breast. 13 "Low-dose mammography" means the x-ray examination of the 14 breast using equipment dedicated specifically for mammography, 15 including the x-ray tube, filter, compression device, and 16 image receptor, with an average radiation exposure delivery of 17 less than one rad per breast for 2 views of an average size 18 breast. The term also includes digital mammography and 19 includes breast tomosynthesis. 20 "Breast tomosynthesis" means a radiologic procedure that 21 involves the acquisition of projection images over the 22 stationary breast to produce cross-sectional digital 23 three-dimensional images of the breast. 24 If, at any time, the Secretary of the United States 25 Department of Health and Human Services, or its successor 26 agency, promulgates rules or regulations to be published in HB1031 - 10 - LRB103 04705 KTG 49714 b HB1031- 11 -LRB103 04705 KTG 49714 b HB1031 - 11 - LRB103 04705 KTG 49714 b HB1031 - 11 - LRB103 04705 KTG 49714 b 1 the Federal Register or publishes a comment in the Federal 2 Register or issues an opinion, guidance, or other action that 3 would require the State, pursuant to any provision of the 4 Patient Protection and Affordable Care Act (Public Law 5 111-148), including, but not limited to, 42 U.S.C. 6 18031(d)(3)(B) or any successor provision, to defray the cost 7 of any coverage for breast tomosynthesis outlined in this 8 paragraph, then the requirement that an insurer cover breast 9 tomosynthesis is inoperative other than any such coverage 10 authorized under Section 1902 of the Social Security Act, 42 11 U.S.C. 1396a, and the State shall not assume any obligation 12 for the cost of coverage for breast tomosynthesis set forth in 13 this paragraph. 14 On and after January 1, 2016, the Department shall ensure 15 that all networks of care for adult clients of the Department 16 include access to at least one breast imaging Center of 17 Imaging Excellence as certified by the American College of 18 Radiology. 19 On and after January 1, 2012, providers participating in a 20 quality improvement program approved by the Department shall 21 be reimbursed for screening and diagnostic mammography at the 22 same rate as the Medicare program's rates, including the 23 increased reimbursement for digital mammography and, after 24 January 1, 2023 (the effective date of Public Act 102-1018) 25 this amendatory Act of the 102nd General Assembly, breast 26 tomosynthesis. HB1031 - 11 - LRB103 04705 KTG 49714 b HB1031- 12 -LRB103 04705 KTG 49714 b HB1031 - 12 - LRB103 04705 KTG 49714 b HB1031 - 12 - LRB103 04705 KTG 49714 b 1 The Department shall convene an expert panel including 2 representatives of hospitals, free-standing mammography 3 facilities, and doctors, including radiologists, to establish 4 quality standards for mammography. 5 On and after January 1, 2017, providers participating in a 6 breast cancer treatment quality improvement program approved 7 by the Department shall be reimbursed for breast cancer 8 treatment at a rate that is no lower than 95% of the Medicare 9 program's rates for the data elements included in the breast 10 cancer treatment quality program. 11 The Department shall convene an expert panel, including 12 representatives of hospitals, free-standing breast cancer 13 treatment centers, breast cancer quality organizations, and 14 doctors, including breast surgeons, reconstructive breast 15 surgeons, oncologists, and primary care providers to establish 16 quality standards for breast cancer treatment. 17 Subject to federal approval, the Department shall 18 establish a rate methodology for mammography at federally 19 qualified health centers and other encounter-rate clinics. 20 These clinics or centers may also collaborate with other 21 hospital-based mammography facilities. By January 1, 2016, the 22 Department shall report to the General Assembly on the status 23 of the provision set forth in this paragraph. 24 The Department shall establish a methodology to remind 25 individuals who are age-appropriate for screening mammography, 26 but who have not received a mammogram within the previous 18 HB1031 - 12 - LRB103 04705 KTG 49714 b HB1031- 13 -LRB103 04705 KTG 49714 b HB1031 - 13 - LRB103 04705 KTG 49714 b HB1031 - 13 - LRB103 04705 KTG 49714 b 1 months, of the importance and benefit of screening 2 mammography. The Department shall work with experts in breast 3 cancer outreach and patient navigation to optimize these 4 reminders and shall establish a methodology for evaluating 5 their effectiveness and modifying the methodology based on the 6 evaluation. 7 The Department shall establish a performance goal for 8 primary care providers with respect to their female patients 9 over age 40 receiving an annual mammogram. This performance 10 goal shall be used to provide additional reimbursement in the 11 form of a quality performance bonus to primary care providers 12 who meet that goal. 13 The Department shall devise a means of case-managing or 14 patient navigation for beneficiaries diagnosed with breast 15 cancer. This program shall initially operate as a pilot 16 program in areas of the State with the highest incidence of 17 mortality related to breast cancer. At least one pilot program 18 site shall be in the metropolitan Chicago area and at least one 19 site shall be outside the metropolitan Chicago area. On or 20 after July 1, 2016, the pilot program shall be expanded to 21 include one site in western Illinois, one site in southern 22 Illinois, one site in central Illinois, and 4 sites within 23 metropolitan Chicago. An evaluation of the pilot program shall 24 be carried out measuring health outcomes and cost of care for 25 those served by the pilot program compared to similarly 26 situated patients who are not served by the pilot program. HB1031 - 13 - LRB103 04705 KTG 49714 b HB1031- 14 -LRB103 04705 KTG 49714 b HB1031 - 14 - LRB103 04705 KTG 49714 b HB1031 - 14 - LRB103 04705 KTG 49714 b 1 The Department shall require all networks of care to 2 develop a means either internally or by contract with experts 3 in navigation and community outreach to navigate cancer 4 patients to comprehensive care in a timely fashion. The 5 Department shall require all networks of care to include 6 access for patients diagnosed with cancer to at least one 7 academic commission on cancer-accredited cancer program as an 8 in-network covered benefit. 9 The Department shall provide coverage and reimbursement 10 for a human papillomavirus (HPV) vaccine that is approved for 11 marketing by the federal Food and Drug Administration for all 12 persons between the ages of 9 and 45 and persons of the age of 13 46 and above who have been diagnosed with cervical dysplasia 14 with a high risk of recurrence or progression. The Department 15 shall disallow any preauthorization requirements for the 16 administration of the human papillomavirus (HPV) vaccine. 17 On or after July 1, 2022, individuals who are otherwise 18 eligible for medical assistance under this Article shall 19 receive coverage for perinatal depression screenings for the 20 12-month period beginning on the last day of their pregnancy. 21 Medical assistance coverage under this paragraph shall be 22 conditioned on the use of a screening instrument approved by 23 the Department. 24 Any medical or health care provider shall immediately 25 recommend, to any pregnant individual who is being provided 26 prenatal services and is suspected of having a substance use HB1031 - 14 - LRB103 04705 KTG 49714 b HB1031- 15 -LRB103 04705 KTG 49714 b HB1031 - 15 - LRB103 04705 KTG 49714 b HB1031 - 15 - LRB103 04705 KTG 49714 b 1 disorder as defined in the Substance Use Disorder Act, 2 referral to a local substance use disorder treatment program 3 licensed by the Department of Human Services or to a licensed 4 hospital which provides substance abuse treatment services. 5 The Department of Healthcare and Family Services shall assure 6 coverage for the cost of treatment of the drug abuse or 7 addiction for pregnant recipients in accordance with the 8 Illinois Medicaid Program in conjunction with the Department 9 of Human Services. 10 All medical providers providing medical assistance to 11 pregnant individuals under this Code shall receive information 12 from the Department on the availability of services under any 13 program providing case management services for addicted 14 individuals, including information on appropriate referrals 15 for other social services that may be needed by addicted 16 individuals in addition to treatment for addiction. 17 The Illinois Department, in cooperation with the 18 Departments of Human Services (as successor to the Department 19 of Alcoholism and Substance Abuse) and Public Health, through 20 a public awareness campaign, may provide information 21 concerning treatment for alcoholism and drug abuse and 22 addiction, prenatal health care, and other pertinent programs 23 directed at reducing the number of drug-affected infants born 24 to recipients of medical assistance. 25 Neither the Department of Healthcare and Family Services 26 nor the Department of Human Services shall sanction the HB1031 - 15 - LRB103 04705 KTG 49714 b HB1031- 16 -LRB103 04705 KTG 49714 b HB1031 - 16 - LRB103 04705 KTG 49714 b HB1031 - 16 - LRB103 04705 KTG 49714 b 1 recipient solely on the basis of the recipient's substance 2 abuse. 3 The Illinois Department shall establish such regulations 4 governing the dispensing of health services under this Article 5 as it shall deem appropriate. The Department should seek the 6 advice of formal professional advisory committees appointed by 7 the Director of the Illinois Department for the purpose of 8 providing regular advice on policy and administrative matters, 9 information dissemination and educational activities for 10 medical and health care providers, and consistency in 11 procedures to the Illinois Department. 12 The Illinois Department may develop and contract with 13 Partnerships of medical providers to arrange medical services 14 for persons eligible under Section 5-2 of this Code. 15 Implementation of this Section may be by demonstration 16 projects in certain geographic areas. The Partnership shall be 17 represented by a sponsor organization. The Department, by 18 rule, shall develop qualifications for sponsors of 19 Partnerships. Nothing in this Section shall be construed to 20 require that the sponsor organization be a medical 21 organization. 22 The sponsor must negotiate formal written contracts with 23 medical providers for physician services, inpatient and 24 outpatient hospital care, home health services, treatment for 25 alcoholism and substance abuse, and other services determined 26 necessary by the Illinois Department by rule for delivery by HB1031 - 16 - LRB103 04705 KTG 49714 b HB1031- 17 -LRB103 04705 KTG 49714 b HB1031 - 17 - LRB103 04705 KTG 49714 b HB1031 - 17 - LRB103 04705 KTG 49714 b 1 Partnerships. Physician services must include prenatal and 2 obstetrical care. The Illinois Department shall reimburse 3 medical services delivered by Partnership providers to clients 4 in target areas according to provisions of this Article and 5 the Illinois Health Finance Reform Act, except that: 6 (1) Physicians participating in a Partnership and 7 providing certain services, which shall be determined by 8 the Illinois Department, to persons in areas covered by 9 the Partnership may receive an additional surcharge for 10 such services. 11 (2) The Department may elect to consider and negotiate 12 financial incentives to encourage the development of 13 Partnerships and the efficient delivery of medical care. 14 (3) Persons receiving medical services through 15 Partnerships may receive medical and case management 16 services above the level usually offered through the 17 medical assistance program. 18 Medical providers shall be required to meet certain 19 qualifications to participate in Partnerships to ensure the 20 delivery of high quality medical services. These 21 qualifications shall be determined by rule of the Illinois 22 Department and may be higher than qualifications for 23 participation in the medical assistance program. Partnership 24 sponsors may prescribe reasonable additional qualifications 25 for participation by medical providers, only with the prior 26 written approval of the Illinois Department. HB1031 - 17 - LRB103 04705 KTG 49714 b HB1031- 18 -LRB103 04705 KTG 49714 b HB1031 - 18 - LRB103 04705 KTG 49714 b HB1031 - 18 - LRB103 04705 KTG 49714 b 1 Nothing in this Section shall limit the free choice of 2 practitioners, hospitals, and other providers of medical 3 services by clients. In order to ensure patient freedom of 4 choice, the Illinois Department shall immediately promulgate 5 all rules and take all other necessary actions so that 6 provided services may be accessed from therapeutically 7 certified optometrists to the full extent of the Illinois 8 Optometric Practice Act of 1987 without discriminating between 9 service providers. 10 The Department shall apply for a waiver from the United 11 States Health Care Financing Administration to allow for the 12 implementation of Partnerships under this Section. 13 The Illinois Department shall require health care 14 providers to maintain records that document the medical care 15 and services provided to recipients of Medical Assistance 16 under this Article. Such records must be retained for a period 17 of not less than 6 years from the date of service or as 18 provided by applicable State law, whichever period is longer, 19 except that if an audit is initiated within the required 20 retention period then the records must be retained until the 21 audit is completed and every exception is resolved. The 22 Illinois Department shall require health care providers to 23 make available, when authorized by the patient, in writing, 24 the medical records in a timely fashion to other health care 25 providers who are treating or serving persons eligible for 26 Medical Assistance under this Article. All dispensers of HB1031 - 18 - LRB103 04705 KTG 49714 b HB1031- 19 -LRB103 04705 KTG 49714 b HB1031 - 19 - LRB103 04705 KTG 49714 b HB1031 - 19 - LRB103 04705 KTG 49714 b 1 medical services shall be required to maintain and retain 2 business and professional records sufficient to fully and 3 accurately document the nature, scope, details and receipt of 4 the health care provided to persons eligible for medical 5 assistance under this Code, in accordance with regulations 6 promulgated by the Illinois Department. The rules and 7 regulations shall require that proof of the receipt of 8 prescription drugs, dentures, prosthetic devices and 9 eyeglasses by eligible persons under this Section accompany 10 each claim for reimbursement submitted by the dispenser of 11 such medical services. No such claims for reimbursement shall 12 be approved for payment by the Illinois Department without 13 such proof of receipt, unless the Illinois Department shall 14 have put into effect and shall be operating a system of 15 post-payment audit and review which shall, on a sampling 16 basis, be deemed adequate by the Illinois Department to assure 17 that such drugs, dentures, prosthetic devices and eyeglasses 18 for which payment is being made are actually being received by 19 eligible recipients. Within 90 days after September 16, 1984 20 (the effective date of Public Act 83-1439), the Illinois 21 Department shall establish a current list of acquisition costs 22 for all prosthetic devices and any other items recognized as 23 medical equipment and supplies reimbursable under this Article 24 and shall update such list on a quarterly basis, except that 25 the acquisition costs of all prescription drugs shall be 26 updated no less frequently than every 30 days as required by HB1031 - 19 - LRB103 04705 KTG 49714 b HB1031- 20 -LRB103 04705 KTG 49714 b HB1031 - 20 - LRB103 04705 KTG 49714 b HB1031 - 20 - LRB103 04705 KTG 49714 b 1 Section 5-5.12. 2 Notwithstanding any other law to the contrary, the 3 Illinois Department shall, within 365 days after July 22, 2013 4 (the effective date of Public Act 98-104), establish 5 procedures to permit skilled care facilities licensed under 6 the Nursing Home Care Act to submit monthly billing claims for 7 reimbursement purposes. Following development of these 8 procedures, the Department shall, by July 1, 2016, test the 9 viability of the new system and implement any necessary 10 operational or structural changes to its information 11 technology platforms in order to allow for the direct 12 acceptance and payment of nursing home claims. 13 Notwithstanding any other law to the contrary, the 14 Illinois Department shall, within 365 days after August 15, 15 2014 (the effective date of Public Act 98-963), establish 16 procedures to permit ID/DD facilities licensed under the ID/DD 17 Community Care Act and MC/DD facilities licensed under the 18 MC/DD Act to submit monthly billing claims for reimbursement 19 purposes. Following development of these procedures, the 20 Department shall have an additional 365 days to test the 21 viability of the new system and to ensure that any necessary 22 operational or structural changes to its information 23 technology platforms are implemented. 24 The Illinois Department shall require all dispensers of 25 medical services, other than an individual practitioner or 26 group of practitioners, desiring to participate in the Medical HB1031 - 20 - LRB103 04705 KTG 49714 b HB1031- 21 -LRB103 04705 KTG 49714 b HB1031 - 21 - LRB103 04705 KTG 49714 b HB1031 - 21 - LRB103 04705 KTG 49714 b 1 Assistance program established under this Article to disclose 2 all financial, beneficial, ownership, equity, surety or other 3 interests in any and all firms, corporations, partnerships, 4 associations, business enterprises, joint ventures, agencies, 5 institutions or other legal entities providing any form of 6 health care services in this State under this Article. 7 The Illinois Department may require that all dispensers of 8 medical services desiring to participate in the medical 9 assistance program established under this Article disclose, 10 under such terms and conditions as the Illinois Department may 11 by rule establish, all inquiries from clients and attorneys 12 regarding medical bills paid by the Illinois Department, which 13 inquiries could indicate potential existence of claims or 14 liens for the Illinois Department. 15 Enrollment of a vendor shall be subject to a provisional 16 period and shall be conditional for one year. During the 17 period of conditional enrollment, the Department may terminate 18 the vendor's eligibility to participate in, or may disenroll 19 the vendor from, the medical assistance program without cause. 20 Unless otherwise specified, such termination of eligibility or 21 disenrollment is not subject to the Department's hearing 22 process. However, a disenrolled vendor may reapply without 23 penalty. 24 The Department has the discretion to limit the conditional 25 enrollment period for vendors based upon category of risk of 26 the vendor. HB1031 - 21 - LRB103 04705 KTG 49714 b HB1031- 22 -LRB103 04705 KTG 49714 b HB1031 - 22 - LRB103 04705 KTG 49714 b HB1031 - 22 - LRB103 04705 KTG 49714 b 1 Prior to enrollment and during the conditional enrollment 2 period in the medical assistance program, all vendors shall be 3 subject to enhanced oversight, screening, and review based on 4 the risk of fraud, waste, and abuse that is posed by the 5 category of risk of the vendor. The Illinois Department shall 6 establish the procedures for oversight, screening, and review, 7 which may include, but need not be limited to: criminal and 8 financial background checks; fingerprinting; license, 9 certification, and authorization verifications; unscheduled or 10 unannounced site visits; database checks; prepayment audit 11 reviews; audits; payment caps; payment suspensions; and other 12 screening as required by federal or State law. 13 The Department shall define or specify the following: (i) 14 by provider notice, the "category of risk of the vendor" for 15 each type of vendor, which shall take into account the level of 16 screening applicable to a particular category of vendor under 17 federal law and regulations; (ii) by rule or provider notice, 18 the maximum length of the conditional enrollment period for 19 each category of risk of the vendor; and (iii) by rule, the 20 hearing rights, if any, afforded to a vendor in each category 21 of risk of the vendor that is terminated or disenrolled during 22 the conditional enrollment period. 23 To be eligible for payment consideration, a vendor's 24 payment claim or bill, either as an initial claim or as a 25 resubmitted claim following prior rejection, must be received 26 by the Illinois Department, or its fiscal intermediary, no HB1031 - 22 - LRB103 04705 KTG 49714 b HB1031- 23 -LRB103 04705 KTG 49714 b HB1031 - 23 - LRB103 04705 KTG 49714 b HB1031 - 23 - LRB103 04705 KTG 49714 b 1 later than 180 days after the latest date on the claim on which 2 medical goods or services were provided, with the following 3 exceptions: 4 (1) In the case of a provider whose enrollment is in 5 process by the Illinois Department, the 180-day period 6 shall not begin until the date on the written notice from 7 the Illinois Department that the provider enrollment is 8 complete. 9 (2) In the case of errors attributable to the Illinois 10 Department or any of its claims processing intermediaries 11 which result in an inability to receive, process, or 12 adjudicate a claim, the 180-day period shall not begin 13 until the provider has been notified of the error. 14 (3) In the case of a provider for whom the Illinois 15 Department initiates the monthly billing process. 16 (4) In the case of a provider operated by a unit of 17 local government with a population exceeding 3,000,000 18 when local government funds finance federal participation 19 for claims payments. 20 For claims for services rendered during a period for which 21 a recipient received retroactive eligibility, claims must be 22 filed within 180 days after the Department determines the 23 applicant is eligible. For claims for which the Illinois 24 Department is not the primary payer, claims must be submitted 25 to the Illinois Department within 180 days after the final 26 adjudication by the primary payer. HB1031 - 23 - LRB103 04705 KTG 49714 b HB1031- 24 -LRB103 04705 KTG 49714 b HB1031 - 24 - LRB103 04705 KTG 49714 b HB1031 - 24 - LRB103 04705 KTG 49714 b 1 In the case of long term care facilities, within 120 2 calendar days of receipt by the facility of required 3 prescreening information, new admissions with associated 4 admission documents shall be submitted through the Medical 5 Electronic Data Interchange (MEDI) or the Recipient 6 Eligibility Verification (REV) System or shall be submitted 7 directly to the Department of Human Services using required 8 admission forms. Effective September 1, 2014, admission 9 documents, including all prescreening information, must be 10 submitted through MEDI or REV. Confirmation numbers assigned 11 to an accepted transaction shall be retained by a facility to 12 verify timely submittal. Once an admission transaction has 13 been completed, all resubmitted claims following prior 14 rejection are subject to receipt no later than 180 days after 15 the admission transaction has been completed. 16 Claims that are not submitted and received in compliance 17 with the foregoing requirements shall not be eligible for 18 payment under the medical assistance program, and the State 19 shall have no liability for payment of those claims. 20 To the extent consistent with applicable information and 21 privacy, security, and disclosure laws, State and federal 22 agencies and departments shall provide the Illinois Department 23 access to confidential and other information and data 24 necessary to perform eligibility and payment verifications and 25 other Illinois Department functions. This includes, but is not 26 limited to: information pertaining to licensure; HB1031 - 24 - LRB103 04705 KTG 49714 b HB1031- 25 -LRB103 04705 KTG 49714 b HB1031 - 25 - LRB103 04705 KTG 49714 b HB1031 - 25 - LRB103 04705 KTG 49714 b 1 certification; earnings; immigration status; citizenship; wage 2 reporting; unearned and earned income; pension income; 3 employment; supplemental security income; social security 4 numbers; National Provider Identifier (NPI) numbers; the 5 National Practitioner Data Bank (NPDB); program and agency 6 exclusions; taxpayer identification numbers; tax delinquency; 7 corporate information; and death records. 8 The Illinois Department shall enter into agreements with 9 State agencies and departments, and is authorized to enter 10 into agreements with federal agencies and departments, under 11 which such agencies and departments shall share data necessary 12 for medical assistance program integrity functions and 13 oversight. The Illinois Department shall develop, in 14 cooperation with other State departments and agencies, and in 15 compliance with applicable federal laws and regulations, 16 appropriate and effective methods to share such data. At a 17 minimum, and to the extent necessary to provide data sharing, 18 the Illinois Department shall enter into agreements with State 19 agencies and departments, and is authorized to enter into 20 agreements with federal agencies and departments, including, 21 but not limited to: the Secretary of State; the Department of 22 Revenue; the Department of Public Health; the Department of 23 Human Services; and the Department of Financial and 24 Professional Regulation. 25 Beginning in fiscal year 2013, the Illinois Department 26 shall set forth a request for information to identify the HB1031 - 25 - LRB103 04705 KTG 49714 b HB1031- 26 -LRB103 04705 KTG 49714 b HB1031 - 26 - LRB103 04705 KTG 49714 b HB1031 - 26 - LRB103 04705 KTG 49714 b 1 benefits of a pre-payment, post-adjudication, and post-edit 2 claims system with the goals of streamlining claims processing 3 and provider reimbursement, reducing the number of pending or 4 rejected claims, and helping to ensure a more transparent 5 adjudication process through the utilization of: (i) provider 6 data verification and provider screening technology; and (ii) 7 clinical code editing; and (iii) pre-pay, pre- or 8 post-adjudicated predictive modeling with an integrated case 9 management system with link analysis. Such a request for 10 information shall not be considered as a request for proposal 11 or as an obligation on the part of the Illinois Department to 12 take any action or acquire any products or services. 13 The Illinois Department shall establish policies, 14 procedures, standards and criteria by rule for the 15 acquisition, repair and replacement of orthotic and prosthetic 16 devices and durable medical equipment. Such rules shall 17 provide, but not be limited to, the following services: (1) 18 immediate repair or replacement of such devices by recipients; 19 and (2) rental, lease, purchase or lease-purchase of durable 20 medical equipment in a cost-effective manner, taking into 21 consideration the recipient's medical prognosis, the extent of 22 the recipient's needs, and the requirements and costs for 23 maintaining such equipment. Subject to prior approval, such 24 rules shall enable a recipient to temporarily acquire and use 25 alternative or substitute devices or equipment pending repairs 26 or replacements of any device or equipment previously HB1031 - 26 - LRB103 04705 KTG 49714 b HB1031- 27 -LRB103 04705 KTG 49714 b HB1031 - 27 - LRB103 04705 KTG 49714 b HB1031 - 27 - LRB103 04705 KTG 49714 b 1 authorized for such recipient by the Department. 2 Notwithstanding any provision of Section 5-5f to the contrary, 3 the Department may, by rule, exempt certain replacement 4 wheelchair parts from prior approval and, for wheelchairs, 5 wheelchair parts, wheelchair accessories, and related seating 6 and positioning items, determine the wholesale price by 7 methods other than actual acquisition costs. 8 The Department shall require, by rule, all providers of 9 durable medical equipment to be accredited by an accreditation 10 organization approved by the federal Centers for Medicare and 11 Medicaid Services and recognized by the Department in order to 12 bill the Department for providing durable medical equipment to 13 recipients. No later than 15 months after the effective date 14 of the rule adopted pursuant to this paragraph, all providers 15 must meet the accreditation requirement. 16 In order to promote environmental responsibility, meet the 17 needs of recipients and enrollees, and achieve significant 18 cost savings, the Department, or a managed care organization 19 under contract with the Department, may provide recipients or 20 managed care enrollees who have a prescription or Certificate 21 of Medical Necessity access to refurbished durable medical 22 equipment under this Section (excluding prosthetic and 23 orthotic devices as defined in the Orthotics, Prosthetics, and 24 Pedorthics Practice Act and complex rehabilitation technology 25 products and associated services) through the State's 26 assistive technology program's reutilization program, using HB1031 - 27 - LRB103 04705 KTG 49714 b HB1031- 28 -LRB103 04705 KTG 49714 b HB1031 - 28 - LRB103 04705 KTG 49714 b HB1031 - 28 - LRB103 04705 KTG 49714 b 1 staff with the Assistive Technology Professional (ATP) 2 Certification if the refurbished durable medical equipment: 3 (i) is available; (ii) is less expensive, including shipping 4 costs, than new durable medical equipment of the same type; 5 (iii) is able to withstand at least 3 years of use; (iv) is 6 cleaned, disinfected, sterilized, and safe in accordance with 7 federal Food and Drug Administration regulations and guidance 8 governing the reprocessing of medical devices in health care 9 settings; and (v) equally meets the needs of the recipient or 10 enrollee. The reutilization program shall confirm that the 11 recipient or enrollee is not already in receipt of the same or 12 similar equipment from another service provider, and that the 13 refurbished durable medical equipment equally meets the needs 14 of the recipient or enrollee. Nothing in this paragraph shall 15 be construed to limit recipient or enrollee choice to obtain 16 new durable medical equipment or place any additional prior 17 authorization conditions on enrollees of managed care 18 organizations. 19 The Department shall execute, relative to the nursing home 20 prescreening project, written inter-agency agreements with the 21 Department of Human Services and the Department on Aging, to 22 effect the following: (i) intake procedures and common 23 eligibility criteria for those persons who are receiving 24 non-institutional services; and (ii) the establishment and 25 development of non-institutional services in areas of the 26 State where they are not currently available or are HB1031 - 28 - LRB103 04705 KTG 49714 b HB1031- 29 -LRB103 04705 KTG 49714 b HB1031 - 29 - LRB103 04705 KTG 49714 b HB1031 - 29 - LRB103 04705 KTG 49714 b 1 undeveloped; and (iii) notwithstanding any other provision of 2 law, subject to federal approval, on and after July 1, 2012, an 3 increase in the determination of need (DON) scores from 29 to 4 37 for applicants for institutional and home and 5 community-based long term care; if and only if federal 6 approval is not granted, the Department may, in conjunction 7 with other affected agencies, implement utilization controls 8 or changes in benefit packages to effectuate a similar savings 9 amount for this population; and (iv) no later than July 1, 10 2013, minimum level of care eligibility criteria for 11 institutional and home and community-based long term care; and 12 (v) no later than October 1, 2013, establish procedures to 13 permit long term care providers access to eligibility scores 14 for individuals with an admission date who are seeking or 15 receiving services from the long term care provider. In order 16 to select the minimum level of care eligibility criteria, the 17 Governor shall establish a workgroup that includes affected 18 agency representatives and stakeholders representing the 19 institutional and home and community-based long term care 20 interests. This Section shall not restrict the Department from 21 implementing lower level of care eligibility criteria for 22 community-based services in circumstances where federal 23 approval has been granted. 24 The Illinois Department shall develop and operate, in 25 cooperation with other State Departments and agencies and in 26 compliance with applicable federal laws and regulations, HB1031 - 29 - LRB103 04705 KTG 49714 b HB1031- 30 -LRB103 04705 KTG 49714 b HB1031 - 30 - LRB103 04705 KTG 49714 b HB1031 - 30 - LRB103 04705 KTG 49714 b 1 appropriate and effective systems of health care evaluation 2 and programs for monitoring of utilization of health care 3 services and facilities, as it affects persons eligible for 4 medical assistance under this Code. 5 The Illinois Department shall report annually to the 6 General Assembly, no later than the second Friday in April of 7 1979 and each year thereafter, in regard to: 8 (a) actual statistics and trends in utilization of 9 medical services by public aid recipients; 10 (b) actual statistics and trends in the provision of 11 the various medical services by medical vendors; 12 (c) current rate structures and proposed changes in 13 those rate structures for the various medical vendors; and 14 (d) efforts at utilization review and control by the 15 Illinois Department. 16 The period covered by each report shall be the 3 years 17 ending on the June 30 prior to the report. The report shall 18 include suggested legislation for consideration by the General 19 Assembly. The requirement for reporting to the General 20 Assembly shall be satisfied by filing copies of the report as 21 required by Section 3.1 of the General Assembly Organization 22 Act, and filing such additional copies with the State 23 Government Report Distribution Center for the General Assembly 24 as is required under paragraph (t) of Section 7 of the State 25 Library Act. 26 Rulemaking authority to implement Public Act 95-1045, if HB1031 - 30 - LRB103 04705 KTG 49714 b HB1031- 31 -LRB103 04705 KTG 49714 b HB1031 - 31 - LRB103 04705 KTG 49714 b HB1031 - 31 - LRB103 04705 KTG 49714 b 1 any, is conditioned on the rules being adopted in accordance 2 with all provisions of the Illinois Administrative Procedure 3 Act and all rules and procedures of the Joint Committee on 4 Administrative Rules; any purported rule not so adopted, for 5 whatever reason, is unauthorized. 6 On and after July 1, 2012, the Department shall reduce any 7 rate of reimbursement for services or other payments or alter 8 any methodologies authorized by this Code to reduce any rate 9 of reimbursement for services or other payments in accordance 10 with Section 5-5e. 11 Because kidney transplantation can be an appropriate, 12 cost-effective alternative to renal dialysis when medically 13 necessary and notwithstanding the provisions of Section 1-11 14 of this Code, beginning October 1, 2014, the Department shall 15 cover kidney transplantation for noncitizens with end-stage 16 renal disease who are not eligible for comprehensive medical 17 benefits, who meet the residency requirements of Section 5-3 18 of this Code, and who would otherwise meet the financial 19 requirements of the appropriate class of eligible persons 20 under Section 5-2 of this Code. To qualify for coverage of 21 kidney transplantation, such person must be receiving 22 emergency renal dialysis services covered by the Department. 23 Providers under this Section shall be prior approved and 24 certified by the Department to perform kidney transplantation 25 and the services under this Section shall be limited to 26 services associated with kidney transplantation. HB1031 - 31 - LRB103 04705 KTG 49714 b HB1031- 32 -LRB103 04705 KTG 49714 b HB1031 - 32 - LRB103 04705 KTG 49714 b HB1031 - 32 - LRB103 04705 KTG 49714 b 1 Notwithstanding any other provision of this Code to the 2 contrary, on or after July 1, 2015, all FDA approved forms of 3 medication assisted treatment prescribed for the treatment of 4 alcohol dependence or treatment of opioid dependence shall be 5 covered under both fee for service and managed care medical 6 assistance programs for persons who are otherwise eligible for 7 medical assistance under this Article and shall not be subject 8 to any (1) utilization control, other than those established 9 under the American Society of Addiction Medicine patient 10 placement criteria, (2) prior authorization mandate, or (3) 11 lifetime restriction limit mandate. 12 On or after July 1, 2015, opioid antagonists prescribed 13 for the treatment of an opioid overdose, including the 14 medication product, administration devices, and any pharmacy 15 fees or hospital fees related to the dispensing, distribution, 16 and administration of the opioid antagonist, shall be covered 17 under the medical assistance program for persons who are 18 otherwise eligible for medical assistance under this Article. 19 As used in this Section, "opioid antagonist" means a drug that 20 binds to opioid receptors and blocks or inhibits the effect of 21 opioids acting on those receptors, including, but not limited 22 to, naloxone hydrochloride or any other similarly acting drug 23 approved by the U.S. Food and Drug Administration. The 24 Department shall not impose a copayment on the coverage 25 provided for naloxone hydrochloride under the medical 26 assistance program. HB1031 - 32 - LRB103 04705 KTG 49714 b HB1031- 33 -LRB103 04705 KTG 49714 b HB1031 - 33 - LRB103 04705 KTG 49714 b HB1031 - 33 - LRB103 04705 KTG 49714 b 1 Upon federal approval, the Department shall provide 2 coverage and reimbursement for all drugs that are approved for 3 marketing by the federal Food and Drug Administration and that 4 are recommended by the federal Public Health Service or the 5 United States Centers for Disease Control and Prevention for 6 pre-exposure prophylaxis and related pre-exposure prophylaxis 7 services, including, but not limited to, HIV and sexually 8 transmitted infection screening, treatment for sexually 9 transmitted infections, medical monitoring, assorted labs, and 10 counseling to reduce the likelihood of HIV infection among 11 individuals who are not infected with HIV but who are at high 12 risk of HIV infection. 13 A federally qualified health center, as defined in Section 14 1905(l)(2)(B) of the federal Social Security Act, shall be 15 reimbursed by the Department in accordance with the federally 16 qualified health center's encounter rate for services provided 17 to medical assistance recipients that are performed by a 18 dental hygienist, as defined under the Illinois Dental 19 Practice Act, working under the general supervision of a 20 dentist and employed by a federally qualified health center. 21 Within 90 days after October 8, 2021 (the effective date 22 of Public Act 102-665), the Department shall seek federal 23 approval of a State Plan amendment to expand coverage for 24 family planning services that includes presumptive eligibility 25 to individuals whose income is at or below 208% of the federal 26 poverty level. Coverage under this Section shall be effective HB1031 - 33 - LRB103 04705 KTG 49714 b HB1031- 34 -LRB103 04705 KTG 49714 b HB1031 - 34 - LRB103 04705 KTG 49714 b HB1031 - 34 - LRB103 04705 KTG 49714 b 1 beginning no later than December 1, 2022. 2 Subject to approval by the federal Centers for Medicare 3 and Medicaid Services of a Title XIX State Plan amendment 4 electing the Program of All-Inclusive Care for the Elderly 5 (PACE) as a State Medicaid option, as provided for by Subtitle 6 I (commencing with Section 4801) of Title IV of the Balanced 7 Budget Act of 1997 (Public Law 105-33) and Part 460 8 (commencing with Section 460.2) of Subchapter E of Title 42 of 9 the Code of Federal Regulations, PACE program services shall 10 become a covered benefit of the medical assistance program, 11 subject to criteria established in accordance with all 12 applicable laws. 13 Notwithstanding any other provision of this Code, 14 community-based pediatric palliative care from a trained 15 interdisciplinary team shall be covered under the medical 16 assistance program as provided in Section 15 of the Pediatric 17 Palliative Care Act. 18 Notwithstanding any other provision of this Code, within 19 12 months after June 2, 2022 (the effective date of Public Act 20 102-1037) this amendatory Act of the 102nd General Assembly 21 and subject to federal approval, acupuncture services 22 performed by an acupuncturist licensed under the Acupuncture 23 Practice Act who is acting within the scope of his or her 24 license shall be covered under the medical assistance program. 25 The Department shall apply for any federal waiver or State 26 Plan amendment, if required, to implement this paragraph. The HB1031 - 34 - LRB103 04705 KTG 49714 b HB1031- 35 -LRB103 04705 KTG 49714 b HB1031 - 35 - LRB103 04705 KTG 49714 b HB1031 - 35 - LRB103 04705 KTG 49714 b 1 Department may adopt any rules, including standards and 2 criteria, necessary to implement this paragraph. 3 To address maternal mental health conditions and reduce 4 the incidence of maternal mortality and morbidity and 5 postpartum depression, pregnant women eligible to receive 6 medical assistance under this Article shall receive coverage 7 for prenatal and postnatal support services during pregnancy 8 and during the 5-year period beginning on the last day of the 9 pregnancy. Prenatal and postnatal support services covered 10 under this paragraph include, but are not limited to, services 11 provided by doulas, lactation counselors, labor assistants, 12 childbirth educators, community mental health centers or 13 behavioral clinics, social workers, and public health nurses 14 as well as any other evidence-based mental health and social 15 care services that are designed to screen, identify, and 16 manage maternal mental disorders. The Department may consult 17 with the Department of Human Services and the Department of 18 Public Health to establish a program of services consistent 19 with the purposes of this paragraph. As used in this 20 paragraph, "doula" means a person certified to provide 21 childbirth education and support services, including emotional 22 and physical support provided during pregnancy, labor, birth, 23 and postpartum. To be eligible for reimbursement for doula 24 services under this paragraph, the individual providing doula 25 services must: (i) be certified by an entity that is 26 nationally recognized for training and certifying doulas and HB1031 - 35 - LRB103 04705 KTG 49714 b HB1031- 36 -LRB103 04705 KTG 49714 b HB1031 - 36 - LRB103 04705 KTG 49714 b HB1031 - 36 - LRB103 04705 KTG 49714 b 1 that is approved by the Department; (ii) have completed a 2 cultural competency course; (iii) have completed a course on 3 Health Insurance Portability and Accountability Act 4 compliance; (iv) be certified to perform cardiopulmonary 5 resuscitation; and (v) be willing to submit to a federal and 6 State criminal history background check. As used in this 7 paragraph, "cultural competency course" means training in 8 cultural sensitivity, cultural respect, and cultural humility 9 that instructs a doula on how to acquire and use knowledge of 10 the health-related beliefs, attitudes, practices, and 11 communication patterns of clients and their families to 12 improve services, strengthen programs, increase community 13 participation, and close the gaps in health status among 14 diverse population groups. The Department shall apply for any 15 federal waiver or State Plan amendment required to implement 16 this Section. Upon federal approval, the Department shall 17 adopt any rules necessary to implement the services covered 18 under this paragraph, including rules on certification or 19 licensing requirements for providers of prenatal and postnatal 20 support services and rules to provide medical assistance 21 reimbursement under this paragraph. 22 (Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; 23 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 24 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 25 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 26 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. HB1031 - 36 - LRB103 04705 KTG 49714 b HB1031- 37 -LRB103 04705 KTG 49714 b HB1031 - 37 - LRB103 04705 KTG 49714 b HB1031 - 37 - LRB103 04705 KTG 49714 b 1 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 2 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff. 3 1-1-23; revised 8-9-22.) HB1031 - 37 - LRB103 04705 KTG 49714 b