Illinois 2023-2024 Regular Session

Illinois House Bill HB1031 Compare Versions

Only one version of the bill is available at this time.

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1	1	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
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5
4	4	305 ILCS 5/5-5 from Ch. 23, par. 5-5
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.
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11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5 as follows:
16	16	6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
17	17	7 (Text of Section after amendment by P.A. 102-1018 and P.A.
18	18	8 102-1038)
19	19	9 Sec. 5-5. Medical services. The Illinois Department, by
20	20	10 rule, shall determine the quantity and quality of and the rate
21	21	11 of reimbursement for the medical assistance for which payment
22	22	12 will be authorized, and the medical services to be provided,
23	23	13 which may include all or part of the following: (1) inpatient
24	24	14 hospital services; (2) outpatient hospital services; (3) other
25	25	15 laboratory and X-ray services; (4) skilled nursing home
26	26	16 services; (5) physicians' services whether furnished in the
27	27	17 office, the patient's home, a hospital, a skilled nursing
28	28	18 home, or elsewhere; (6) medical care, or any other type of
29	29	19 remedial care furnished by licensed practitioners; (7) home
30	30	20 health care services; (8) private duty nursing service; (9)
31	31	21 clinic services; (10) dental services, including prevention
32	32	22 and treatment of periodontal disease and dental caries disease
33	33	23 for pregnant individuals, provided by an individual licensed
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1031 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5 from Ch. 23, par. 5-5 305 ILCS 5/5-5 from Ch. 23, par. 5-5
39	39	305 ILCS 5/5-5 from Ch. 23, par. 5-5
40	40	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.
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68	68	1 to practice dentistry or dental surgery; for purposes of this
69	69	2 item (10), "dental services" means diagnostic, preventive, or
70	70	3 corrective procedures provided by or under the supervision of
71	71	4 a dentist in the practice of his or her profession; (11)
72	72	5 physical therapy and related services; (12) prescribed drugs,
73	73	6 dentures, and prosthetic devices; and eyeglasses prescribed by
74	74	7 a physician skilled in the diseases of the eye, or by an
75	75	8 optometrist, whichever the person may select; (13) other
76	76	9 diagnostic, screening, preventive, and rehabilitative
77	77	10 services, including to ensure that the individual's need for
78	78	11 intervention or treatment of mental disorders or substance use
79	79	12 disorders or co-occurring mental health and substance use
80	80	13 disorders is determined using a uniform screening, assessment,
81	81	14 and evaluation process inclusive of criteria, for children and
82	82	15 adults; for purposes of this item (13), a uniform screening,
83	83	16 assessment, and evaluation process refers to a process that
84	84	17 includes an appropriate evaluation and, as warranted, a
85	85	18 referral; "uniform" does not mean the use of a singular
86	86	19 instrument, tool, or process that all must utilize; (14)
87	87	20 transportation and such other expenses as may be necessary;
88	88	21 (15) medical treatment of sexual assault survivors, as defined
89	89	22 in Section 1a of the Sexual Assault Survivors Emergency
90	90	23 Treatment Act, for injuries sustained as a result of the
91	91	24 sexual assault, including examinations and laboratory tests to
92	92	25 discover evidence which may be used in criminal proceedings
93	93	26 arising from the sexual assault; (16) the diagnosis and
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104	104	1 treatment of sickle cell anemia; (16.5) services performed by
105	105	2 a chiropractic physician licensed under the Medical Practice
106	106	3 Act of 1987 and acting within the scope of his or her license,
107	107	4 including, but not limited to, chiropractic manipulative
108	108	5 treatment; and (17) any other medical care, and any other type
109	109	6 of remedial care recognized under the laws of this State. The
110	110	7 term "any other type of remedial care" shall include nursing
111	111	8 care and nursing home service for persons who rely on
112	112	9 treatment by spiritual means alone through prayer for healing.
113	113	10 Notwithstanding any other provision of this Section, a
114	114	11 comprehensive tobacco use cessation program that includes
115	115	12 purchasing prescription drugs or prescription medical devices
116	116	13 approved by the Food and Drug Administration shall be covered
117	117	14 under the medical assistance program under this Article for
118	118	15 persons who are otherwise eligible for assistance under this
119	119	16 Article.
120	120	17 Notwithstanding any other provision of this Code,
121	121	18 reproductive health care that is otherwise legal in Illinois
122	122	19 shall be covered under the medical assistance program for
123	123	20 persons who are otherwise eligible for medical assistance
124	124	21 under this Article.
125	125	22 Notwithstanding any other provision of this Section, all
126	126	23 tobacco cessation medications approved by the United States
127	127	24 Food and Drug Administration and all individual and group
128	128	25 tobacco cessation counseling services and telephone-based
129	129	26 counseling services and tobacco cessation medications provided
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140	140	1 through the Illinois Tobacco Quitline shall be covered under
141	141	2 the medical assistance program for persons who are otherwise
142	142	3 eligible for assistance under this Article. The Department
143	143	4 shall comply with all federal requirements necessary to obtain
144	144	5 federal financial participation, as specified in 42 CFR
145	145	6 433.15(b)(7), for telephone-based counseling services provided
146	146	7 through the Illinois Tobacco Quitline, including, but not
147	147	8 limited to: (i) entering into a memorandum of understanding or
148	148	9 interagency agreement with the Department of Public Health, as
149	149	10 administrator of the Illinois Tobacco Quitline; and (ii)
150	150	11 developing a cost allocation plan for Medicaid-allowable
151	151	12 Illinois Tobacco Quitline services in accordance with 45 CFR
152	152	13 95.507. The Department shall submit the memorandum of
153	153	14 understanding or interagency agreement, the cost allocation
154	154	15 plan, and all other necessary documentation to the Centers for
155	155	16 Medicare and Medicaid Services for review and approval.
156	156	17 Coverage under this paragraph shall be contingent upon federal
157	157	18 approval.
158	158	19 Notwithstanding any other provision of this Code, the
159	159	20 Illinois Department may not require, as a condition of payment
160	160	21 for any laboratory test authorized under this Article, that a
161	161	22 physician's handwritten signature appear on the laboratory
162	162	23 test order form. The Illinois Department may, however, impose
163	163	24 other appropriate requirements regarding laboratory test order
164	164	25 documentation.
165	165	26 Upon receipt of federal approval of an amendment to the
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176	176	1 Illinois Title XIX State Plan for this purpose, the Department
177	177	2 shall authorize the Chicago Public Schools (CPS) to procure a
178	178	3 vendor or vendors to manufacture eyeglasses for individuals
179	179	4 enrolled in a school within the CPS system. CPS shall ensure
180	180	5 that its vendor or vendors are enrolled as providers in the
181	181	6 medical assistance program and in any capitated Medicaid
182	182	7 managed care entity (MCE) serving individuals enrolled in a
183	183	8 school within the CPS system. Under any contract procured
184	184	9 under this provision, the vendor or vendors must serve only
185	185	10 individuals enrolled in a school within the CPS system. Claims
186	186	11 for services provided by CPS's vendor or vendors to recipients
187	187	12 of benefits in the medical assistance program under this Code,
188	188	13 the Children's Health Insurance Program, or the Covering ALL
189	189	14 KIDS Health Insurance Program shall be submitted to the
190	190	15 Department or the MCE in which the individual is enrolled for
191	191	16 payment and shall be reimbursed at the Department's or the
192	192	17 MCE's established rates or rate methodologies for eyeglasses.
193	193	18 On and after July 1, 2012, the Department of Healthcare
194	194	19 and Family Services may provide the following services to
195	195	20 persons eligible for assistance under this Article who are
196	196	21 participating in education, training or employment programs
197	197	22 operated by the Department of Human Services as successor to
198	198	23 the Department of Public Aid:
199	199	24 (1) dental services provided by or under the
200	200	25 supervision of a dentist; and
201	201	26 (2) eyeglasses prescribed by a physician skilled in
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212	212	1 the diseases of the eye, or by an optometrist, whichever
213	213	2 the person may select.
214	214	3 On and after July 1, 2018, the Department of Healthcare
215	215	4 and Family Services shall provide dental services to any adult
216	216	5 who is otherwise eligible for assistance under the medical
217	217	6 assistance program. As used in this paragraph, "dental
218	218	7 services" means diagnostic, preventative, restorative, or
219	219	8 corrective procedures, including procedures and services for
220	220	9 the prevention and treatment of periodontal disease and dental
221	221	10 caries disease, provided by an individual who is licensed to
222	222	11 practice dentistry or dental surgery or who is under the
223	223	12 supervision of a dentist in the practice of his or her
224	224	13 profession.
225	225	14 On and after July 1, 2018, targeted dental services, as
226	226	15 set forth in Exhibit D of the Consent Decree entered by the
227	227	16 United States District Court for the Northern District of
228	228	17 Illinois, Eastern Division, in the matter of Memisovski v.
229	229	18 Maram, Case No. 92 C 1982, that are provided to adults under
230	230	19 the medical assistance program shall be established at no less
231	231	20 than the rates set forth in the "New Rate" column in Exhibit D
232	232	21 of the Consent Decree for targeted dental services that are
233	233	22 provided to persons under the age of 18 under the medical
234	234	23 assistance program.
235	235	24 Notwithstanding any other provision of this Code and
236	236	25 subject to federal approval, the Department may adopt rules to
237	237	26 allow a dentist who is volunteering his or her service at no
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248	248	1 cost to render dental services through an enrolled
249	249	2 not-for-profit health clinic without the dentist personally
250	250	3 enrolling as a participating provider in the medical
251	251	4 assistance program. A not-for-profit health clinic shall
252	252	5 include a public health clinic or Federally Qualified Health
253	253	6 Center or other enrolled provider, as determined by the
254	254	7 Department, through which dental services covered under this
255	255	8 Section are performed. The Department shall establish a
256	256	9 process for payment of claims for reimbursement for covered
257	257	10 dental services rendered under this provision.
258	258	11 On and after January 1, 2022, the Department of Healthcare
259	259	12 and Family Services shall administer and regulate a
260	260	13 school-based dental program that allows for the out-of-office
261	261	14 delivery of preventative dental services in a school setting
262	262	15 to children under 19 years of age. The Department shall
263	263	16 establish, by rule, guidelines for participation by providers
264	264	17 and set requirements for follow-up referral care based on the
265	265	18 requirements established in the Dental Office Reference Manual
266	266	19 published by the Department that establishes the requirements
267	267	20 for dentists participating in the All Kids Dental School
268	268	21 Program. Every effort shall be made by the Department when
269	269	22 developing the program requirements to consider the different
270	270	23 geographic differences of both urban and rural areas of the
271	271	24 State for initial treatment and necessary follow-up care. No
272	272	25 provider shall be charged a fee by any unit of local government
273	273	26 to participate in the school-based dental program administered
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284	284	1 by the Department. Nothing in this paragraph shall be
285	285	2 construed to limit or preempt a home rule unit's or school
286	286	3 district's authority to establish, change, or administer a
287	287	4 school-based dental program in addition to, or independent of,
288	288	5 the school-based dental program administered by the
289	289	6 Department.
290	290	7 The Illinois Department, by rule, may distinguish and
291	291	8 classify the medical services to be provided only in
292	292	9 accordance with the classes of persons designated in Section
293	293	10 5-2.
294	294	11 The Department of Healthcare and Family Services must
295	295	12 provide coverage and reimbursement for amino acid-based
296	296	13 elemental formulas, regardless of delivery method, for the
297	297	14 diagnosis and treatment of (i) eosinophilic disorders and (ii)
298	298	15 short bowel syndrome when the prescribing physician has issued
299	299	16 a written order stating that the amino acid-based elemental
300	300	17 formula is medically necessary.
301	301	18 The Illinois Department shall authorize the provision of,
302	302	19 and shall authorize payment for, screening by low-dose
303	303	20 mammography for the presence of occult breast cancer for
304	304	21 individuals 35 years of age or older who are eligible for
305	305	22 medical assistance under this Article, as follows:
306	306	23 (A) A baseline mammogram for individuals 35 to 39
307	307	24 years of age.
308	308	25 (B) An annual mammogram for individuals 40 years of
309	309	26 age or older.
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320	320	1 (C) A mammogram at the age and intervals considered
321	321	2 medically necessary by the individual's health care
322	322	3 provider for individuals under 40 years of age and having
323	323	4 a family history of breast cancer, prior personal history
324	324	5 of breast cancer, positive genetic testing, or other risk
325	325	6 factors.
326	326	7 (D) A comprehensive ultrasound screening and MRI of an
327	327	8 entire breast or breasts if a mammogram demonstrates
328	328	9 heterogeneous or dense breast tissue or when medically
329	329	10 necessary as determined by a physician licensed to
330	330	11 practice medicine in all of its branches.
331	331	12 (E) A screening MRI when medically necessary, as
332	332	13 determined by a physician licensed to practice medicine in
333	333	14 all of its branches.
334	334	15 (F) A diagnostic mammogram when medically necessary,
335	335	16 as determined by a physician licensed to practice medicine
336	336	17 in all its branches, advanced practice registered nurse,
337	337	18 or physician assistant.
338	338	19 The Department shall not impose a deductible, coinsurance,
339	339	20 copayment, or any other cost-sharing requirement on the
340	340	21 coverage provided under this paragraph; except that this
341	341	22 sentence does not apply to coverage of diagnostic mammograms
342	342	23 to the extent such coverage would disqualify a high-deductible
343	343	24 health plan from eligibility for a health savings account
344	344	25 pursuant to Section 223 of the Internal Revenue Code (26
345	345	26 U.S.C. 223).
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356	356	1 All screenings shall include a physical breast exam,
357	357	2 instruction on self-examination and information regarding the
358	358	3 frequency of self-examination and its value as a preventative
359	359	4 tool.
360	360	5 For purposes of this Section:
361	361	6 "Diagnostic mammogram" means a mammogram obtained using
362	362	7 diagnostic mammography.
363	363	8 "Diagnostic mammography" means a method of screening that
364	364	9 is designed to evaluate an abnormality in a breast, including
365	365	10 an abnormality seen or suspected on a screening mammogram or a
366	366	11 subjective or objective abnormality otherwise detected in the
367	367	12 breast.
368	368	13 "Low-dose mammography" means the x-ray examination of the
369	369	14 breast using equipment dedicated specifically for mammography,
370	370	15 including the x-ray tube, filter, compression device, and
371	371	16 image receptor, with an average radiation exposure delivery of
372	372	17 less than one rad per breast for 2 views of an average size
373	373	18 breast. The term also includes digital mammography and
374	374	19 includes breast tomosynthesis.
375	375	20 "Breast tomosynthesis" means a radiologic procedure that
376	376	21 involves the acquisition of projection images over the
377	377	22 stationary breast to produce cross-sectional digital
378	378	23 three-dimensional images of the breast.
379	379	24 If, at any time, the Secretary of the United States
380	380	25 Department of Health and Human Services, or its successor
381	381	26 agency, promulgates rules or regulations to be published in
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392	392	1 the Federal Register or publishes a comment in the Federal
393	393	2 Register or issues an opinion, guidance, or other action that
394	394	3 would require the State, pursuant to any provision of the
395	395	4 Patient Protection and Affordable Care Act (Public Law
396	396	5 111-148), including, but not limited to, 42 U.S.C.
397	397	6 18031(d)(3)(B) or any successor provision, to defray the cost
398	398	7 of any coverage for breast tomosynthesis outlined in this
399	399	8 paragraph, then the requirement that an insurer cover breast
400	400	9 tomosynthesis is inoperative other than any such coverage
401	401	10 authorized under Section 1902 of the Social Security Act, 42
402	402	11 U.S.C. 1396a, and the State shall not assume any obligation
403	403	12 for the cost of coverage for breast tomosynthesis set forth in
404	404	13 this paragraph.
405	405	14 On and after January 1, 2016, the Department shall ensure
406	406	15 that all networks of care for adult clients of the Department
407	407	16 include access to at least one breast imaging Center of
408	408	17 Imaging Excellence as certified by the American College of
409	409	18 Radiology.
410	410	19 On and after January 1, 2012, providers participating in a
411	411	20 quality improvement program approved by the Department shall
412	412	21 be reimbursed for screening and diagnostic mammography at the
413	413	22 same rate as the Medicare program's rates, including the
414	414	23 increased reimbursement for digital mammography and, after
415	415	24 January 1, 2023 (the effective date of Public Act 102-1018)
416	416	25 this amendatory Act of the 102nd General Assembly, breast
417	417	26 tomosynthesis.
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428	428	1 The Department shall convene an expert panel including
429	429	2 representatives of hospitals, free-standing mammography
430	430	3 facilities, and doctors, including radiologists, to establish
431	431	4 quality standards for mammography.
432	432	5 On and after January 1, 2017, providers participating in a
433	433	6 breast cancer treatment quality improvement program approved
434	434	7 by the Department shall be reimbursed for breast cancer
435	435	8 treatment at a rate that is no lower than 95% of the Medicare
436	436	9 program's rates for the data elements included in the breast
437	437	10 cancer treatment quality program.
438	438	11 The Department shall convene an expert panel, including
439	439	12 representatives of hospitals, free-standing breast cancer
440	440	13 treatment centers, breast cancer quality organizations, and
441	441	14 doctors, including breast surgeons, reconstructive breast
442	442	15 surgeons, oncologists, and primary care providers to establish
443	443	16 quality standards for breast cancer treatment.
444	444	17 Subject to federal approval, the Department shall
445	445	18 establish a rate methodology for mammography at federally
446	446	19 qualified health centers and other encounter-rate clinics.
447	447	20 These clinics or centers may also collaborate with other
448	448	21 hospital-based mammography facilities. By January 1, 2016, the
449	449	22 Department shall report to the General Assembly on the status
450	450	23 of the provision set forth in this paragraph.
451	451	24 The Department shall establish a methodology to remind
452	452	25 individuals who are age-appropriate for screening mammography,
453	453	26 but who have not received a mammogram within the previous 18
454	454
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456	456
457	457
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464	464	1 months, of the importance and benefit of screening
465	465	2 mammography. The Department shall work with experts in breast
466	466	3 cancer outreach and patient navigation to optimize these
467	467	4 reminders and shall establish a methodology for evaluating
468	468	5 their effectiveness and modifying the methodology based on the
469	469	6 evaluation.
470	470	7 The Department shall establish a performance goal for
471	471	8 primary care providers with respect to their female patients
472	472	9 over age 40 receiving an annual mammogram. This performance
473	473	10 goal shall be used to provide additional reimbursement in the
474	474	11 form of a quality performance bonus to primary care providers
475	475	12 who meet that goal.
476	476	13 The Department shall devise a means of case-managing or
477	477	14 patient navigation for beneficiaries diagnosed with breast
478	478	15 cancer. This program shall initially operate as a pilot
479	479	16 program in areas of the State with the highest incidence of
480	480	17 mortality related to breast cancer. At least one pilot program
481	481	18 site shall be in the metropolitan Chicago area and at least one
482	482	19 site shall be outside the metropolitan Chicago area. On or
483	483	20 after July 1, 2016, the pilot program shall be expanded to
484	484	21 include one site in western Illinois, one site in southern
485	485	22 Illinois, one site in central Illinois, and 4 sites within
486	486	23 metropolitan Chicago. An evaluation of the pilot program shall
487	487	24 be carried out measuring health outcomes and cost of care for
488	488	25 those served by the pilot program compared to similarly
489	489	26 situated patients who are not served by the pilot program.
490	490
491	491
492	492
493	493
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500	500	1 The Department shall require all networks of care to
501	501	2 develop a means either internally or by contract with experts
502	502	3 in navigation and community outreach to navigate cancer
503	503	4 patients to comprehensive care in a timely fashion. The
504	504	5 Department shall require all networks of care to include
505	505	6 access for patients diagnosed with cancer to at least one
506	506	7 academic commission on cancer-accredited cancer program as an
507	507	8 in-network covered benefit.
508	508	9 The Department shall provide coverage and reimbursement
509	509	10 for a human papillomavirus (HPV) vaccine that is approved for
510	510	11 marketing by the federal Food and Drug Administration for all
511	511	12 persons between the ages of 9 and 45 and persons of the age of
512	512	13 46 and above who have been diagnosed with cervical dysplasia
513	513	14 with a high risk of recurrence or progression. The Department
514	514	15 shall disallow any preauthorization requirements for the
515	515	16 administration of the human papillomavirus (HPV) vaccine.
516	516	17 On or after July 1, 2022, individuals who are otherwise
517	517	18 eligible for medical assistance under this Article shall
518	518	19 receive coverage for perinatal depression screenings for the
519	519	20 12-month period beginning on the last day of their pregnancy.
520	520	21 Medical assistance coverage under this paragraph shall be
521	521	22 conditioned on the use of a screening instrument approved by
522	522	23 the Department.
523	523	24 Any medical or health care provider shall immediately
524	524	25 recommend, to any pregnant individual who is being provided
525	525	26 prenatal services and is suspected of having a substance use
526	526
527	527
528	528
529	529
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536	536	1 disorder as defined in the Substance Use Disorder Act,
537	537	2 referral to a local substance use disorder treatment program
538	538	3 licensed by the Department of Human Services or to a licensed
539	539	4 hospital which provides substance abuse treatment services.
540	540	5 The Department of Healthcare and Family Services shall assure
541	541	6 coverage for the cost of treatment of the drug abuse or
542	542	7 addiction for pregnant recipients in accordance with the
543	543	8 Illinois Medicaid Program in conjunction with the Department
544	544	9 of Human Services.
545	545	10 All medical providers providing medical assistance to
546	546	11 pregnant individuals under this Code shall receive information
547	547	12 from the Department on the availability of services under any
548	548	13 program providing case management services for addicted
549	549	14 individuals, including information on appropriate referrals
550	550	15 for other social services that may be needed by addicted
551	551	16 individuals in addition to treatment for addiction.
552	552	17 The Illinois Department, in cooperation with the
553	553	18 Departments of Human Services (as successor to the Department
554	554	19 of Alcoholism and Substance Abuse) and Public Health, through
555	555	20 a public awareness campaign, may provide information
556	556	21 concerning treatment for alcoholism and drug abuse and
557	557	22 addiction, prenatal health care, and other pertinent programs
558	558	23 directed at reducing the number of drug-affected infants born
559	559	24 to recipients of medical assistance.
560	560	25 Neither the Department of Healthcare and Family Services
561	561	26 nor the Department of Human Services shall sanction the
562	562
563	563
564	564
565	565
566	566
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572	572	1 recipient solely on the basis of the recipient's substance
573	573	2 abuse.
574	574	3 The Illinois Department shall establish such regulations
575	575	4 governing the dispensing of health services under this Article
576	576	5 as it shall deem appropriate. The Department should seek the
577	577	6 advice of formal professional advisory committees appointed by
578	578	7 the Director of the Illinois Department for the purpose of
579	579	8 providing regular advice on policy and administrative matters,
580	580	9 information dissemination and educational activities for
581	581	10 medical and health care providers, and consistency in
582	582	11 procedures to the Illinois Department.
583	583	12 The Illinois Department may develop and contract with
584	584	13 Partnerships of medical providers to arrange medical services
585	585	14 for persons eligible under Section 5-2 of this Code.
586	586	15 Implementation of this Section may be by demonstration
587	587	16 projects in certain geographic areas. The Partnership shall be
588	588	17 represented by a sponsor organization. The Department, by
589	589	18 rule, shall develop qualifications for sponsors of
590	590	19 Partnerships. Nothing in this Section shall be construed to
591	591	20 require that the sponsor organization be a medical
592	592	21 organization.
593	593	22 The sponsor must negotiate formal written contracts with
594	594	23 medical providers for physician services, inpatient and
595	595	24 outpatient hospital care, home health services, treatment for
596	596	25 alcoholism and substance abuse, and other services determined
597	597	26 necessary by the Illinois Department by rule for delivery by
598	598
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601	601
602	602
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608	608	1 Partnerships. Physician services must include prenatal and
609	609	2 obstetrical care. The Illinois Department shall reimburse
610	610	3 medical services delivered by Partnership providers to clients
611	611	4 in target areas according to provisions of this Article and
612	612	5 the Illinois Health Finance Reform Act, except that:
613	613	6 (1) Physicians participating in a Partnership and
614	614	7 providing certain services, which shall be determined by
615	615	8 the Illinois Department, to persons in areas covered by
616	616	9 the Partnership may receive an additional surcharge for
617	617	10 such services.
618	618	11 (2) The Department may elect to consider and negotiate
619	619	12 financial incentives to encourage the development of
620	620	13 Partnerships and the efficient delivery of medical care.
621	621	14 (3) Persons receiving medical services through
622	622	15 Partnerships may receive medical and case management
623	623	16 services above the level usually offered through the
624	624	17 medical assistance program.
625	625	18 Medical providers shall be required to meet certain
626	626	19 qualifications to participate in Partnerships to ensure the
627	627	20 delivery of high quality medical services. These
628	628	21 qualifications shall be determined by rule of the Illinois
629	629	22 Department and may be higher than qualifications for
630	630	23 participation in the medical assistance program. Partnership
631	631	24 sponsors may prescribe reasonable additional qualifications
632	632	25 for participation by medical providers, only with the prior
633	633	26 written approval of the Illinois Department.
634	634
635	635
636	636
637	637
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644	644	1 Nothing in this Section shall limit the free choice of
645	645	2 practitioners, hospitals, and other providers of medical
646	646	3 services by clients. In order to ensure patient freedom of
647	647	4 choice, the Illinois Department shall immediately promulgate
648	648	5 all rules and take all other necessary actions so that
649	649	6 provided services may be accessed from therapeutically
650	650	7 certified optometrists to the full extent of the Illinois
651	651	8 Optometric Practice Act of 1987 without discriminating between
652	652	9 service providers.
653	653	10 The Department shall apply for a waiver from the United
654	654	11 States Health Care Financing Administration to allow for the
655	655	12 implementation of Partnerships under this Section.
656	656	13 The Illinois Department shall require health care
657	657	14 providers to maintain records that document the medical care
658	658	15 and services provided to recipients of Medical Assistance
659	659	16 under this Article. Such records must be retained for a period
660	660	17 of not less than 6 years from the date of service or as
661	661	18 provided by applicable State law, whichever period is longer,
662	662	19 except that if an audit is initiated within the required
663	663	20 retention period then the records must be retained until the
664	664	21 audit is completed and every exception is resolved. The
665	665	22 Illinois Department shall require health care providers to
666	666	23 make available, when authorized by the patient, in writing,
667	667	24 the medical records in a timely fashion to other health care
668	668	25 providers who are treating or serving persons eligible for
669	669	26 Medical Assistance under this Article. All dispensers of
670	670
671	671
672	672
673	673
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680	680	1 medical services shall be required to maintain and retain
681	681	2 business and professional records sufficient to fully and
682	682	3 accurately document the nature, scope, details and receipt of
683	683	4 the health care provided to persons eligible for medical
684	684	5 assistance under this Code, in accordance with regulations
685	685	6 promulgated by the Illinois Department. The rules and
686	686	7 regulations shall require that proof of the receipt of
687	687	8 prescription drugs, dentures, prosthetic devices and
688	688	9 eyeglasses by eligible persons under this Section accompany
689	689	10 each claim for reimbursement submitted by the dispenser of
690	690	11 such medical services. No such claims for reimbursement shall
691	691	12 be approved for payment by the Illinois Department without
692	692	13 such proof of receipt, unless the Illinois Department shall
693	693	14 have put into effect and shall be operating a system of
694	694	15 post-payment audit and review which shall, on a sampling
695	695	16 basis, be deemed adequate by the Illinois Department to assure
696	696	17 that such drugs, dentures, prosthetic devices and eyeglasses
697	697	18 for which payment is being made are actually being received by
698	698	19 eligible recipients. Within 90 days after September 16, 1984
699	699	20 (the effective date of Public Act 83-1439), the Illinois
700	700	21 Department shall establish a current list of acquisition costs
701	701	22 for all prosthetic devices and any other items recognized as
702	702	23 medical equipment and supplies reimbursable under this Article
703	703	24 and shall update such list on a quarterly basis, except that
704	704	25 the acquisition costs of all prescription drugs shall be
705	705	26 updated no less frequently than every 30 days as required by
706	706
707	707
708	708
709	709
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716	716	1 Section 5-5.12.
717	717	2 Notwithstanding any other law to the contrary, the
718	718	3 Illinois Department shall, within 365 days after July 22, 2013
719	719	4 (the effective date of Public Act 98-104), establish
720	720	5 procedures to permit skilled care facilities licensed under
721	721	6 the Nursing Home Care Act to submit monthly billing claims for
722	722	7 reimbursement purposes. Following development of these
723	723	8 procedures, the Department shall, by July 1, 2016, test the
724	724	9 viability of the new system and implement any necessary
725	725	10 operational or structural changes to its information
726	726	11 technology platforms in order to allow for the direct
727	727	12 acceptance and payment of nursing home claims.
728	728	13 Notwithstanding any other law to the contrary, the
729	729	14 Illinois Department shall, within 365 days after August 15,
730	730	15 2014 (the effective date of Public Act 98-963), establish
731	731	16 procedures to permit ID/DD facilities licensed under the ID/DD
732	732	17 Community Care Act and MC/DD facilities licensed under the
733	733	18 MC/DD Act to submit monthly billing claims for reimbursement
734	734	19 purposes. Following development of these procedures, the
735	735	20 Department shall have an additional 365 days to test the
736	736	21 viability of the new system and to ensure that any necessary
737	737	22 operational or structural changes to its information
738	738	23 technology platforms are implemented.
739	739	24 The Illinois Department shall require all dispensers of
740	740	25 medical services, other than an individual practitioner or
741	741	26 group of practitioners, desiring to participate in the Medical
742	742
743	743
744	744
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752	752	1 Assistance program established under this Article to disclose
753	753	2 all financial, beneficial, ownership, equity, surety or other
754	754	3 interests in any and all firms, corporations, partnerships,
755	755	4 associations, business enterprises, joint ventures, agencies,
756	756	5 institutions or other legal entities providing any form of
757	757	6 health care services in this State under this Article.
758	758	7 The Illinois Department may require that all dispensers of
759	759	8 medical services desiring to participate in the medical
760	760	9 assistance program established under this Article disclose,
761	761	10 under such terms and conditions as the Illinois Department may
762	762	11 by rule establish, all inquiries from clients and attorneys
763	763	12 regarding medical bills paid by the Illinois Department, which
764	764	13 inquiries could indicate potential existence of claims or
765	765	14 liens for the Illinois Department.
766	766	15 Enrollment of a vendor shall be subject to a provisional
767	767	16 period and shall be conditional for one year. During the
768	768	17 period of conditional enrollment, the Department may terminate
769	769	18 the vendor's eligibility to participate in, or may disenroll
770	770	19 the vendor from, the medical assistance program without cause.
771	771	20 Unless otherwise specified, such termination of eligibility or
772	772	21 disenrollment is not subject to the Department's hearing
773	773	22 process. However, a disenrolled vendor may reapply without
774	774	23 penalty.
775	775	24 The Department has the discretion to limit the conditional
776	776	25 enrollment period for vendors based upon category of risk of
777	777	26 the vendor.
778	778
779	779
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788	788	1 Prior to enrollment and during the conditional enrollment
789	789	2 period in the medical assistance program, all vendors shall be
790	790	3 subject to enhanced oversight, screening, and review based on
791	791	4 the risk of fraud, waste, and abuse that is posed by the
792	792	5 category of risk of the vendor. The Illinois Department shall
793	793	6 establish the procedures for oversight, screening, and review,
794	794	7 which may include, but need not be limited to: criminal and
795	795	8 financial background checks; fingerprinting; license,
796	796	9 certification, and authorization verifications; unscheduled or
797	797	10 unannounced site visits; database checks; prepayment audit
798	798	11 reviews; audits; payment caps; payment suspensions; and other
799	799	12 screening as required by federal or State law.
800	800	13 The Department shall define or specify the following: (i)
801	801	14 by provider notice, the "category of risk of the vendor" for
802	802	15 each type of vendor, which shall take into account the level of
803	803	16 screening applicable to a particular category of vendor under
804	804	17 federal law and regulations; (ii) by rule or provider notice,
805	805	18 the maximum length of the conditional enrollment period for
806	806	19 each category of risk of the vendor; and (iii) by rule, the
807	807	20 hearing rights, if any, afforded to a vendor in each category
808	808	21 of risk of the vendor that is terminated or disenrolled during
809	809	22 the conditional enrollment period.
810	810	23 To be eligible for payment consideration, a vendor's
811	811	24 payment claim or bill, either as an initial claim or as a
812	812	25 resubmitted claim following prior rejection, must be received
813	813	26 by the Illinois Department, or its fiscal intermediary, no
814	814
815	815
816	816
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824	824	1 later than 180 days after the latest date on the claim on which
825	825	2 medical goods or services were provided, with the following
826	826	3 exceptions:
827	827	4 (1) In the case of a provider whose enrollment is in
828	828	5 process by the Illinois Department, the 180-day period
829	829	6 shall not begin until the date on the written notice from
830	830	7 the Illinois Department that the provider enrollment is
831	831	8 complete.
832	832	9 (2) In the case of errors attributable to the Illinois
833	833	10 Department or any of its claims processing intermediaries
834	834	11 which result in an inability to receive, process, or
835	835	12 adjudicate a claim, the 180-day period shall not begin
836	836	13 until the provider has been notified of the error.
837	837	14 (3) In the case of a provider for whom the Illinois
838	838	15 Department initiates the monthly billing process.
839	839	16 (4) In the case of a provider operated by a unit of
840	840	17 local government with a population exceeding 3,000,000
841	841	18 when local government funds finance federal participation
842	842	19 for claims payments.
843	843	20 For claims for services rendered during a period for which
844	844	21 a recipient received retroactive eligibility, claims must be
845	845	22 filed within 180 days after the Department determines the
846	846	23 applicant is eligible. For claims for which the Illinois
847	847	24 Department is not the primary payer, claims must be submitted
848	848	25 to the Illinois Department within 180 days after the final
849	849	26 adjudication by the primary payer.
850	850
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853	853
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860	860	1 In the case of long term care facilities, within 120
861	861	2 calendar days of receipt by the facility of required
862	862	3 prescreening information, new admissions with associated
863	863	4 admission documents shall be submitted through the Medical
864	864	5 Electronic Data Interchange (MEDI) or the Recipient
865	865	6 Eligibility Verification (REV) System or shall be submitted
866	866	7 directly to the Department of Human Services using required
867	867	8 admission forms. Effective September 1, 2014, admission
868	868	9 documents, including all prescreening information, must be
869	869	10 submitted through MEDI or REV. Confirmation numbers assigned
870	870	11 to an accepted transaction shall be retained by a facility to
871	871	12 verify timely submittal. Once an admission transaction has
872	872	13 been completed, all resubmitted claims following prior
873	873	14 rejection are subject to receipt no later than 180 days after
874	874	15 the admission transaction has been completed.
875	875	16 Claims that are not submitted and received in compliance
876	876	17 with the foregoing requirements shall not be eligible for
877	877	18 payment under the medical assistance program, and the State
878	878	19 shall have no liability for payment of those claims.
879	879	20 To the extent consistent with applicable information and
880	880	21 privacy, security, and disclosure laws, State and federal
881	881	22 agencies and departments shall provide the Illinois Department
882	882	23 access to confidential and other information and data
883	883	24 necessary to perform eligibility and payment verifications and
884	884	25 other Illinois Department functions. This includes, but is not
885	885	26 limited to: information pertaining to licensure;
886	886
887	887
888	888
889	889
890	890
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896	896	1 certification; earnings; immigration status; citizenship; wage
897	897	2 reporting; unearned and earned income; pension income;
898	898	3 employment; supplemental security income; social security
899	899	4 numbers; National Provider Identifier (NPI) numbers; the
900	900	5 National Practitioner Data Bank (NPDB); program and agency
901	901	6 exclusions; taxpayer identification numbers; tax delinquency;
902	902	7 corporate information; and death records.
903	903	8 The Illinois Department shall enter into agreements with
904	904	9 State agencies and departments, and is authorized to enter
905	905	10 into agreements with federal agencies and departments, under
906	906	11 which such agencies and departments shall share data necessary
907	907	12 for medical assistance program integrity functions and
908	908	13 oversight. The Illinois Department shall develop, in
909	909	14 cooperation with other State departments and agencies, and in
910	910	15 compliance with applicable federal laws and regulations,
911	911	16 appropriate and effective methods to share such data. At a
912	912	17 minimum, and to the extent necessary to provide data sharing,
913	913	18 the Illinois Department shall enter into agreements with State
914	914	19 agencies and departments, and is authorized to enter into
915	915	20 agreements with federal agencies and departments, including,
916	916	21 but not limited to: the Secretary of State; the Department of
917	917	22 Revenue; the Department of Public Health; the Department of
918	918	23 Human Services; and the Department of Financial and
919	919	24 Professional Regulation.
920	920	25 Beginning in fiscal year 2013, the Illinois Department
921	921	26 shall set forth a request for information to identify the
922	922
923	923
924	924
925	925
926	926
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929	929
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932	932	1 benefits of a pre-payment, post-adjudication, and post-edit
933	933	2 claims system with the goals of streamlining claims processing
934	934	3 and provider reimbursement, reducing the number of pending or
935	935	4 rejected claims, and helping to ensure a more transparent
936	936	5 adjudication process through the utilization of: (i) provider
937	937	6 data verification and provider screening technology; and (ii)
938	938	7 clinical code editing; and (iii) pre-pay, pre- or
939	939	8 post-adjudicated predictive modeling with an integrated case
940	940	9 management system with link analysis. Such a request for
941	941	10 information shall not be considered as a request for proposal
942	942	11 or as an obligation on the part of the Illinois Department to
943	943	12 take any action or acquire any products or services.
944	944	13 The Illinois Department shall establish policies,
945	945	14 procedures, standards and criteria by rule for the
946	946	15 acquisition, repair and replacement of orthotic and prosthetic
947	947	16 devices and durable medical equipment. Such rules shall
948	948	17 provide, but not be limited to, the following services: (1)
949	949	18 immediate repair or replacement of such devices by recipients;
950	950	19 and (2) rental, lease, purchase or lease-purchase of durable
951	951	20 medical equipment in a cost-effective manner, taking into
952	952	21 consideration the recipient's medical prognosis, the extent of
953	953	22 the recipient's needs, and the requirements and costs for
954	954	23 maintaining such equipment. Subject to prior approval, such
955	955	24 rules shall enable a recipient to temporarily acquire and use
956	956	25 alternative or substitute devices or equipment pending repairs
957	957	26 or replacements of any device or equipment previously
958	958
959	959
960	960
961	961
962	962
963	963	HB1031 - 26 - LRB103 04705 KTG 49714 b
964	964
965	965
966	966	HB1031- 27 -LRB103 04705 KTG 49714 b HB1031 - 27 - LRB103 04705 KTG 49714 b
967	967	HB1031 - 27 - LRB103 04705 KTG 49714 b
968	968	1 authorized for such recipient by the Department.
969	969	2 Notwithstanding any provision of Section 5-5f to the contrary,
970	970	3 the Department may, by rule, exempt certain replacement
971	971	4 wheelchair parts from prior approval and, for wheelchairs,
972	972	5 wheelchair parts, wheelchair accessories, and related seating
973	973	6 and positioning items, determine the wholesale price by
974	974	7 methods other than actual acquisition costs.
975	975	8 The Department shall require, by rule, all providers of
976	976	9 durable medical equipment to be accredited by an accreditation
977	977	10 organization approved by the federal Centers for Medicare and
978	978	11 Medicaid Services and recognized by the Department in order to
979	979	12 bill the Department for providing durable medical equipment to
980	980	13 recipients. No later than 15 months after the effective date
981	981	14 of the rule adopted pursuant to this paragraph, all providers
982	982	15 must meet the accreditation requirement.
983	983	16 In order to promote environmental responsibility, meet the
984	984	17 needs of recipients and enrollees, and achieve significant
985	985	18 cost savings, the Department, or a managed care organization
986	986	19 under contract with the Department, may provide recipients or
987	987	20 managed care enrollees who have a prescription or Certificate
988	988	21 of Medical Necessity access to refurbished durable medical
989	989	22 equipment under this Section (excluding prosthetic and
990	990	23 orthotic devices as defined in the Orthotics, Prosthetics, and
991	991	24 Pedorthics Practice Act and complex rehabilitation technology
992	992	25 products and associated services) through the State's
993	993	26 assistive technology program's reutilization program, using
994	994
995	995
996	996
997	997
998	998
999	999	HB1031 - 27 - LRB103 04705 KTG 49714 b
1000	1000
1001	1001
1002	1002	HB1031- 28 -LRB103 04705 KTG 49714 b HB1031 - 28 - LRB103 04705 KTG 49714 b
1003	1003	HB1031 - 28 - LRB103 04705 KTG 49714 b
1004	1004	1 staff with the Assistive Technology Professional (ATP)
1005	1005	2 Certification if the refurbished durable medical equipment:
1006	1006	3 (i) is available; (ii) is less expensive, including shipping
1007	1007	4 costs, than new durable medical equipment of the same type;
1008	1008	5 (iii) is able to withstand at least 3 years of use; (iv) is
1009	1009	6 cleaned, disinfected, sterilized, and safe in accordance with
1010	1010	7 federal Food and Drug Administration regulations and guidance
1011	1011	8 governing the reprocessing of medical devices in health care
1012	1012	9 settings; and (v) equally meets the needs of the recipient or
1013	1013	10 enrollee. The reutilization program shall confirm that the
1014	1014	11 recipient or enrollee is not already in receipt of the same or
1015	1015	12 similar equipment from another service provider, and that the
1016	1016	13 refurbished durable medical equipment equally meets the needs
1017	1017	14 of the recipient or enrollee. Nothing in this paragraph shall
1018	1018	15 be construed to limit recipient or enrollee choice to obtain
1019	1019	16 new durable medical equipment or place any additional prior
1020	1020	17 authorization conditions on enrollees of managed care
1021	1021	18 organizations.
1022	1022	19 The Department shall execute, relative to the nursing home
1023	1023	20 prescreening project, written inter-agency agreements with the
1024	1024	21 Department of Human Services and the Department on Aging, to
1025	1025	22 effect the following: (i) intake procedures and common
1026	1026	23 eligibility criteria for those persons who are receiving
1027	1027	24 non-institutional services; and (ii) the establishment and
1028	1028	25 development of non-institutional services in areas of the
1029	1029	26 State where they are not currently available or are
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB1031 - 28 - LRB103 04705 KTG 49714 b
1036	1036
1037	1037
1038	1038	HB1031- 29 -LRB103 04705 KTG 49714 b HB1031 - 29 - LRB103 04705 KTG 49714 b
1039	1039	HB1031 - 29 - LRB103 04705 KTG 49714 b
1040	1040	1 undeveloped; and (iii) notwithstanding any other provision of
1041	1041	2 law, subject to federal approval, on and after July 1, 2012, an
1042	1042	3 increase in the determination of need (DON) scores from 29 to
1043	1043	4 37 for applicants for institutional and home and
1044	1044	5 community-based long term care; if and only if federal
1045	1045	6 approval is not granted, the Department may, in conjunction
1046	1046	7 with other affected agencies, implement utilization controls
1047	1047	8 or changes in benefit packages to effectuate a similar savings
1048	1048	9 amount for this population; and (iv) no later than July 1,
1049	1049	10 2013, minimum level of care eligibility criteria for
1050	1050	11 institutional and home and community-based long term care; and
1051	1051	12 (v) no later than October 1, 2013, establish procedures to
1052	1052	13 permit long term care providers access to eligibility scores
1053	1053	14 for individuals with an admission date who are seeking or
1054	1054	15 receiving services from the long term care provider. In order
1055	1055	16 to select the minimum level of care eligibility criteria, the
1056	1056	17 Governor shall establish a workgroup that includes affected
1057	1057	18 agency representatives and stakeholders representing the
1058	1058	19 institutional and home and community-based long term care
1059	1059	20 interests. This Section shall not restrict the Department from
1060	1060	21 implementing lower level of care eligibility criteria for
1061	1061	22 community-based services in circumstances where federal
1062	1062	23 approval has been granted.
1063	1063	24 The Illinois Department shall develop and operate, in
1064	1064	25 cooperation with other State Departments and agencies and in
1065	1065	26 compliance with applicable federal laws and regulations,
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB1031 - 29 - LRB103 04705 KTG 49714 b
1072	1072
1073	1073
1074	1074	HB1031- 30 -LRB103 04705 KTG 49714 b HB1031 - 30 - LRB103 04705 KTG 49714 b
1075	1075	HB1031 - 30 - LRB103 04705 KTG 49714 b
1076	1076	1 appropriate and effective systems of health care evaluation
1077	1077	2 and programs for monitoring of utilization of health care
1078	1078	3 services and facilities, as it affects persons eligible for
1079	1079	4 medical assistance under this Code.
1080	1080	5 The Illinois Department shall report annually to the
1081	1081	6 General Assembly, no later than the second Friday in April of
1082	1082	7 1979 and each year thereafter, in regard to:
1083	1083	8 (a) actual statistics and trends in utilization of
1084	1084	9 medical services by public aid recipients;
1085	1085	10 (b) actual statistics and trends in the provision of
1086	1086	11 the various medical services by medical vendors;
1087	1087	12 (c) current rate structures and proposed changes in
1088	1088	13 those rate structures for the various medical vendors; and
1089	1089	14 (d) efforts at utilization review and control by the
1090	1090	15 Illinois Department.
1091	1091	16 The period covered by each report shall be the 3 years
1092	1092	17 ending on the June 30 prior to the report. The report shall
1093	1093	18 include suggested legislation for consideration by the General
1094	1094	19 Assembly. The requirement for reporting to the General
1095	1095	20 Assembly shall be satisfied by filing copies of the report as
1096	1096	21 required by Section 3.1 of the General Assembly Organization
1097	1097	22 Act, and filing such additional copies with the State
1098	1098	23 Government Report Distribution Center for the General Assembly
1099	1099	24 as is required under paragraph (t) of Section 7 of the State
1100	1100	25 Library Act.
1101	1101	26 Rulemaking authority to implement Public Act 95-1045, if
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB1031 - 30 - LRB103 04705 KTG 49714 b
1108	1108
1109	1109
1110	1110	HB1031- 31 -LRB103 04705 KTG 49714 b HB1031 - 31 - LRB103 04705 KTG 49714 b
1111	1111	HB1031 - 31 - LRB103 04705 KTG 49714 b
1112	1112	1 any, is conditioned on the rules being adopted in accordance
1113	1113	2 with all provisions of the Illinois Administrative Procedure
1114	1114	3 Act and all rules and procedures of the Joint Committee on
1115	1115	4 Administrative Rules; any purported rule not so adopted, for
1116	1116	5 whatever reason, is unauthorized.
1117	1117	6 On and after July 1, 2012, the Department shall reduce any
1118	1118	7 rate of reimbursement for services or other payments or alter
1119	1119	8 any methodologies authorized by this Code to reduce any rate
1120	1120	9 of reimbursement for services or other payments in accordance
1121	1121	10 with Section 5-5e.
1122	1122	11 Because kidney transplantation can be an appropriate,
1123	1123	12 cost-effective alternative to renal dialysis when medically
1124	1124	13 necessary and notwithstanding the provisions of Section 1-11
1125	1125	14 of this Code, beginning October 1, 2014, the Department shall
1126	1126	15 cover kidney transplantation for noncitizens with end-stage
1127	1127	16 renal disease who are not eligible for comprehensive medical
1128	1128	17 benefits, who meet the residency requirements of Section 5-3
1129	1129	18 of this Code, and who would otherwise meet the financial
1130	1130	19 requirements of the appropriate class of eligible persons
1131	1131	20 under Section 5-2 of this Code. To qualify for coverage of
1132	1132	21 kidney transplantation, such person must be receiving
1133	1133	22 emergency renal dialysis services covered by the Department.
1134	1134	23 Providers under this Section shall be prior approved and
1135	1135	24 certified by the Department to perform kidney transplantation
1136	1136	25 and the services under this Section shall be limited to
1137	1137	26 services associated with kidney transplantation.
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB1031 - 31 - LRB103 04705 KTG 49714 b
1144	1144
1145	1145
1146	1146	HB1031- 32 -LRB103 04705 KTG 49714 b HB1031 - 32 - LRB103 04705 KTG 49714 b
1147	1147	HB1031 - 32 - LRB103 04705 KTG 49714 b
1148	1148	1 Notwithstanding any other provision of this Code to the
1149	1149	2 contrary, on or after July 1, 2015, all FDA approved forms of
1150	1150	3 medication assisted treatment prescribed for the treatment of
1151	1151	4 alcohol dependence or treatment of opioid dependence shall be
1152	1152	5 covered under both fee for service and managed care medical
1153	1153	6 assistance programs for persons who are otherwise eligible for
1154	1154	7 medical assistance under this Article and shall not be subject
1155	1155	8 to any (1) utilization control, other than those established
1156	1156	9 under the American Society of Addiction Medicine patient
1157	1157	10 placement criteria, (2) prior authorization mandate, or (3)
1158	1158	11 lifetime restriction limit mandate.
1159	1159	12 On or after July 1, 2015, opioid antagonists prescribed
1160	1160	13 for the treatment of an opioid overdose, including the
1161	1161	14 medication product, administration devices, and any pharmacy
1162	1162	15 fees or hospital fees related to the dispensing, distribution,
1163	1163	16 and administration of the opioid antagonist, shall be covered
1164	1164	17 under the medical assistance program for persons who are
1165	1165	18 otherwise eligible for medical assistance under this Article.
1166	1166	19 As used in this Section, "opioid antagonist" means a drug that
1167	1167	20 binds to opioid receptors and blocks or inhibits the effect of
1168	1168	21 opioids acting on those receptors, including, but not limited
1169	1169	22 to, naloxone hydrochloride or any other similarly acting drug
1170	1170	23 approved by the U.S. Food and Drug Administration. The
1171	1171	24 Department shall not impose a copayment on the coverage
1172	1172	25 provided for naloxone hydrochloride under the medical
1173	1173	26 assistance program.
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB1031 - 32 - LRB103 04705 KTG 49714 b
1180	1180
1181	1181
1182	1182	HB1031- 33 -LRB103 04705 KTG 49714 b HB1031 - 33 - LRB103 04705 KTG 49714 b
1183	1183	HB1031 - 33 - LRB103 04705 KTG 49714 b
1184	1184	1 Upon federal approval, the Department shall provide
1185	1185	2 coverage and reimbursement for all drugs that are approved for
1186	1186	3 marketing by the federal Food and Drug Administration and that
1187	1187	4 are recommended by the federal Public Health Service or the
1188	1188	5 United States Centers for Disease Control and Prevention for
1189	1189	6 pre-exposure prophylaxis and related pre-exposure prophylaxis
1190	1190	7 services, including, but not limited to, HIV and sexually
1191	1191	8 transmitted infection screening, treatment for sexually
1192	1192	9 transmitted infections, medical monitoring, assorted labs, and
1193	1193	10 counseling to reduce the likelihood of HIV infection among
1194	1194	11 individuals who are not infected with HIV but who are at high
1195	1195	12 risk of HIV infection.
1196	1196	13 A federally qualified health center, as defined in Section
1197	1197	14 1905(l)(2)(B) of the federal Social Security Act, shall be
1198	1198	15 reimbursed by the Department in accordance with the federally
1199	1199	16 qualified health center's encounter rate for services provided
1200	1200	17 to medical assistance recipients that are performed by a
1201	1201	18 dental hygienist, as defined under the Illinois Dental
1202	1202	19 Practice Act, working under the general supervision of a
1203	1203	20 dentist and employed by a federally qualified health center.
1204	1204	21 Within 90 days after October 8, 2021 (the effective date
1205	1205	22 of Public Act 102-665), the Department shall seek federal
1206	1206	23 approval of a State Plan amendment to expand coverage for
1207	1207	24 family planning services that includes presumptive eligibility
1208	1208	25 to individuals whose income is at or below 208% of the federal
1209	1209	26 poverty level. Coverage under this Section shall be effective
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB1031 - 33 - LRB103 04705 KTG 49714 b
1216	1216
1217	1217
1218	1218	HB1031- 34 -LRB103 04705 KTG 49714 b HB1031 - 34 - LRB103 04705 KTG 49714 b
1219	1219	HB1031 - 34 - LRB103 04705 KTG 49714 b
1220	1220	1 beginning no later than December 1, 2022.
1221	1221	2 Subject to approval by the federal Centers for Medicare
1222	1222	3 and Medicaid Services of a Title XIX State Plan amendment
1223	1223	4 electing the Program of All-Inclusive Care for the Elderly
1224	1224	5 (PACE) as a State Medicaid option, as provided for by Subtitle
1225	1225	6 I (commencing with Section 4801) of Title IV of the Balanced
1226	1226	7 Budget Act of 1997 (Public Law 105-33) and Part 460
1227	1227	8 (commencing with Section 460.2) of Subchapter E of Title 42 of
1228	1228	9 the Code of Federal Regulations, PACE program services shall
1229	1229	10 become a covered benefit of the medical assistance program,
1230	1230	11 subject to criteria established in accordance with all
1231	1231	12 applicable laws.
1232	1232	13 Notwithstanding any other provision of this Code,
1233	1233	14 community-based pediatric palliative care from a trained
1234	1234	15 interdisciplinary team shall be covered under the medical
1235	1235	16 assistance program as provided in Section 15 of the Pediatric
1236	1236	17 Palliative Care Act.
1237	1237	18 Notwithstanding any other provision of this Code, within
1238	1238	19 12 months after June 2, 2022 (the effective date of Public Act
1239	1239	20 102-1037) this amendatory Act of the 102nd General Assembly
1240	1240	21 and subject to federal approval, acupuncture services
1241	1241	22 performed by an acupuncturist licensed under the Acupuncture
1242	1242	23 Practice Act who is acting within the scope of his or her
1243	1243	24 license shall be covered under the medical assistance program.
1244	1244	25 The Department shall apply for any federal waiver or State
1245	1245	26 Plan amendment, if required, to implement this paragraph. The
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
1251	1251	HB1031 - 34 - LRB103 04705 KTG 49714 b
1252	1252
1253	1253
1254	1254	HB1031- 35 -LRB103 04705 KTG 49714 b HB1031 - 35 - LRB103 04705 KTG 49714 b
1255	1255	HB1031 - 35 - LRB103 04705 KTG 49714 b
1256	1256	1 Department may adopt any rules, including standards and
1257	1257	2 criteria, necessary to implement this paragraph.
1258	1258	3 To address maternal mental health conditions and reduce
1259	1259	4 the incidence of maternal mortality and morbidity and
1260	1260	5 postpartum depression, pregnant women eligible to receive
1261	1261	6 medical assistance under this Article shall receive coverage
1262	1262	7 for prenatal and postnatal support services during pregnancy
1263	1263	8 and during the 5-year period beginning on the last day of the
1264	1264	9 pregnancy. Prenatal and postnatal support services covered
1265	1265	10 under this paragraph include, but are not limited to, services
1266	1266	11 provided by doulas, lactation counselors, labor assistants,
1267	1267	12 childbirth educators, community mental health centers or
1268	1268	13 behavioral clinics, social workers, and public health nurses
1269	1269	14 as well as any other evidence-based mental health and social
1270	1270	15 care services that are designed to screen, identify, and
1271	1271	16 manage maternal mental disorders. The Department may consult
1272	1272	17 with the Department of Human Services and the Department of
1273	1273	18 Public Health to establish a program of services consistent
1274	1274	19 with the purposes of this paragraph. As used in this
1275	1275	20 paragraph, "doula" means a person certified to provide
1276	1276	21 childbirth education and support services, including emotional
1277	1277	22 and physical support provided during pregnancy, labor, birth,
1278	1278	23 and postpartum. To be eligible for reimbursement for doula
1279	1279	24 services under this paragraph, the individual providing doula
1280	1280	25 services must: (i) be certified by an entity that is
1281	1281	26 nationally recognized for training and certifying doulas and
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
1287	1287	HB1031 - 35 - LRB103 04705 KTG 49714 b
1288	1288
1289	1289
1290	1290	HB1031- 36 -LRB103 04705 KTG 49714 b HB1031 - 36 - LRB103 04705 KTG 49714 b
1291	1291	HB1031 - 36 - LRB103 04705 KTG 49714 b
1292	1292	1 that is approved by the Department; (ii) have completed a
1293	1293	2 cultural competency course; (iii) have completed a course on
1294	1294	3 Health Insurance Portability and Accountability Act
1295	1295	4 compliance; (iv) be certified to perform cardiopulmonary
1296	1296	5 resuscitation; and (v) be willing to submit to a federal and
1297	1297	6 State criminal history background check. As used in this
1298	1298	7 paragraph, "cultural competency course" means training in
1299	1299	8 cultural sensitivity, cultural respect, and cultural humility
1300	1300	9 that instructs a doula on how to acquire and use knowledge of
1301	1301	10 the health-related beliefs, attitudes, practices, and
1302	1302	11 communication patterns of clients and their families to
1303	1303	12 improve services, strengthen programs, increase community
1304	1304	13 participation, and close the gaps in health status among
1305	1305	14 diverse population groups. The Department shall apply for any
1306	1306	15 federal waiver or State Plan amendment required to implement
1307	1307	16 this Section. Upon federal approval, the Department shall
1308	1308	17 adopt any rules necessary to implement the services covered
1309	1309	18 under this paragraph, including rules on certification or
1310	1310	19 licensing requirements for providers of prenatal and postnatal
1311	1311	20 support services and rules to provide medical assistance
1312	1312	21 reimbursement under this paragraph.
1313	1313	22 (Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
1314	1314	23 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1315	1315	24 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1316	1316	25 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
1317	1317	26 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1318	1318
1319	1319
1320	1320
1321	1321
1322	1322
1323	1323	HB1031 - 36 - LRB103 04705 KTG 49714 b
1324	1324
1325	1325
1326	1326	HB1031- 37 -LRB103 04705 KTG 49714 b HB1031 - 37 - LRB103 04705 KTG 49714 b
1327	1327	HB1031 - 37 - LRB103 04705 KTG 49714 b
1328	1328	1 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
1329	1329	2 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1330	1330	3 1-1-23; revised 8-9-22.)
1331	1331
1332	1332
1333	1333
1334	1334
1335	1335
1336	1336	HB1031 - 37 - LRB103 04705 KTG 49714 b