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Illinois House Bill HB1384

Illinois 2023-2024 Regular Session

Illinois House Bill HB1384 Compare Versions

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1-Public Act 103-0123
21 HB1384 EnrolledLRB103 25389 BMS 51735 b HB1384 Enrolled LRB103 25389 BMS 51735 b
32 HB1384 Enrolled LRB103 25389 BMS 51735 b
4-AN ACT concerning regulation.
5-Be it enacted by the People of the State of Illinois,
6-represented in the General Assembly:
7-Section 5. The Illinois Insurance Code is amended by
8-adding Section 356z.61 as follows:
9-(215 ILCS 5/356z.61 new)
10-Sec. 356z.61. Coverage for reconstructive services.
11-(a) As used in this Section, "reconstructive services"
12-means treatments performed on structures of the body damaged
13-by trauma to restore physical appearance.
14-(b) A group or individual policy of accident and health
15-insurance or a managed care plan that is amended, delivered,
16-issued, or renewed on or after January 1, 2025 may not deny
17-coverage for medically necessary reconstructive services that
18-are intended to restore physical appearance.
19-Section 10. The Health Maintenance Organization Act is
20-amended by changing Section 5-3 as follows:
21-(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
22-Sec. 5-3. Insurance Code provisions.
23-(a) Health Maintenance Organizations shall be subject to
24-the provisions of Sections 133, 134, 136, 137, 139, 140,
3+1 AN ACT concerning regulation.
4+2 Be it enacted by the People of the State of Illinois,
5+3 represented in the General Assembly:
6+4 Section 5. The Illinois Insurance Code is amended by
7+5 adding Section 356z.61 as follows:
8+6 (215 ILCS 5/356z.61 new)
9+7 Sec. 356z.61. Coverage for reconstructive services.
10+8 (a) As used in this Section, "reconstructive services"
11+9 means treatments performed on structures of the body damaged
12+10 by trauma to restore physical appearance.
13+11 (b) A group or individual policy of accident and health
14+12 insurance or a managed care plan that is amended, delivered,
15+13 issued, or renewed on or after January 1, 2025 may not deny
16+14 coverage for medically necessary reconstructive services that
17+15 are intended to restore physical appearance.
18+16 Section 10. The Health Maintenance Organization Act is
19+17 amended by changing Section 5-3 as follows:
20+18 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
21+19 Sec. 5-3. Insurance Code provisions.
22+20 (a) Health Maintenance Organizations shall be subject to
23+21 the provisions of Sections 133, 134, 136, 137, 139, 140,
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31-141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
32-154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
33-355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
34-356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
35-356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
36-356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
37-356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
38-356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47, 356z.48,
39-356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56, 356z.57,
40-356z.59, 356z.60, 356z.61, 364, 364.01, 364.3, 367.2, 367.2-5,
41-367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
42-402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
43-paragraph (c) of subsection (2) of Section 367, and Articles
44-IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
45-XXXIIB of the Illinois Insurance Code.
46-(b) For purposes of the Illinois Insurance Code, except
47-for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
48-Health Maintenance Organizations in the following categories
49-are deemed to be "domestic companies":
50-(1) a corporation authorized under the Dental Service
51-Plan Act or the Voluntary Health Services Plans Act;
52-(2) a corporation organized under the laws of this
53-State; or
54-(3) a corporation organized under the laws of another
55-state, 30% or more of the enrollees of which are residents
56-of this State, except a corporation subject to
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32+1 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
33+2 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
34+3 355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
35+4 356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
36+5 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
37+6 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
38+7 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
39+8 356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47, 356z.48,
40+9 356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56, 356z.57,
41+10 356z.59, 356z.60, 356z.61, 364, 364.01, 364.3, 367.2, 367.2-5,
42+11 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
43+12 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
44+13 paragraph (c) of subsection (2) of Section 367, and Articles
45+14 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
46+15 XXXIIB of the Illinois Insurance Code.
47+16 (b) For purposes of the Illinois Insurance Code, except
48+17 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
49+18 Health Maintenance Organizations in the following categories
50+19 are deemed to be "domestic companies":
51+20 (1) a corporation authorized under the Dental Service
52+21 Plan Act or the Voluntary Health Services Plans Act;
53+22 (2) a corporation organized under the laws of this
54+23 State; or
55+24 (3) a corporation organized under the laws of another
56+25 state, 30% or more of the enrollees of which are residents
57+26 of this State, except a corporation subject to
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59-substantially the same requirements in its state of
60-organization as is a "domestic company" under Article VIII
61-1/2 of the Illinois Insurance Code.
62-(c) In considering the merger, consolidation, or other
63-acquisition of control of a Health Maintenance Organization
64-pursuant to Article VIII 1/2 of the Illinois Insurance Code,
65-(1) the Director shall give primary consideration to
66-the continuation of benefits to enrollees and the
67-financial conditions of the acquired Health Maintenance
68-Organization after the merger, consolidation, or other
69-acquisition of control takes effect;
70-(2)(i) the criteria specified in subsection (1)(b) of
71-Section 131.8 of the Illinois Insurance Code shall not
72-apply and (ii) the Director, in making his determination
73-with respect to the merger, consolidation, or other
74-acquisition of control, need not take into account the
75-effect on competition of the merger, consolidation, or
76-other acquisition of control;
77-(3) the Director shall have the power to require the
78-following information:
79-(A) certification by an independent actuary of the
80-adequacy of the reserves of the Health Maintenance
81-Organization sought to be acquired;
82-(B) pro forma financial statements reflecting the
83-combined balance sheets of the acquiring company and
84-the Health Maintenance Organization sought to be
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87-acquired as of the end of the preceding year and as of
88-a date 90 days prior to the acquisition, as well as pro
89-forma financial statements reflecting projected
90-combined operation for a period of 2 years;
91-(C) a pro forma business plan detailing an
92-acquiring party's plans with respect to the operation
93-of the Health Maintenance Organization sought to be
94-acquired for a period of not less than 3 years; and
95-(D) such other information as the Director shall
96-require.
97-(d) The provisions of Article VIII 1/2 of the Illinois
98-Insurance Code and this Section 5-3 shall apply to the sale by
99-any health maintenance organization of greater than 10% of its
100-enrollee population (including without limitation the health
101-maintenance organization's right, title, and interest in and
102-to its health care certificates).
103-(e) In considering any management contract or service
104-agreement subject to Section 141.1 of the Illinois Insurance
105-Code, the Director (i) shall, in addition to the criteria
106-specified in Section 141.2 of the Illinois Insurance Code,
107-take into account the effect of the management contract or
108-service agreement on the continuation of benefits to enrollees
109-and the financial condition of the health maintenance
110-organization to be managed or serviced, and (ii) need not take
111-into account the effect of the management contract or service
112-agreement on competition.
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115-(f) Except for small employer groups as defined in the
116-Small Employer Rating, Renewability and Portability Health
117-Insurance Act and except for medicare supplement policies as
118-defined in Section 363 of the Illinois Insurance Code, a
119-Health Maintenance Organization may by contract agree with a
120-group or other enrollment unit to effect refunds or charge
121-additional premiums under the following terms and conditions:
122-(i) the amount of, and other terms and conditions with
123-respect to, the refund or additional premium are set forth
124-in the group or enrollment unit contract agreed in advance
125-of the period for which a refund is to be paid or
126-additional premium is to be charged (which period shall
127-not be less than one year); and
128-(ii) the amount of the refund or additional premium
129-shall not exceed 20% of the Health Maintenance
130-Organization's profitable or unprofitable experience with
131-respect to the group or other enrollment unit for the
132-period (and, for purposes of a refund or additional
133-premium, the profitable or unprofitable experience shall
134-be calculated taking into account a pro rata share of the
135-Health Maintenance Organization's administrative and
136-marketing expenses, but shall not include any refund to be
137-made or additional premium to be paid pursuant to this
138-subsection (f)). The Health Maintenance Organization and
139-the group or enrollment unit may agree that the profitable
140-or unprofitable experience may be calculated taking into
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68+1 substantially the same requirements in its state of
69+2 organization as is a "domestic company" under Article VIII
70+3 1/2 of the Illinois Insurance Code.
71+4 (c) In considering the merger, consolidation, or other
72+5 acquisition of control of a Health Maintenance Organization
73+6 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
74+7 (1) the Director shall give primary consideration to
75+8 the continuation of benefits to enrollees and the
76+9 financial conditions of the acquired Health Maintenance
77+10 Organization after the merger, consolidation, or other
78+11 acquisition of control takes effect;
79+12 (2)(i) the criteria specified in subsection (1)(b) of
80+13 Section 131.8 of the Illinois Insurance Code shall not
81+14 apply and (ii) the Director, in making his determination
82+15 with respect to the merger, consolidation, or other
83+16 acquisition of control, need not take into account the
84+17 effect on competition of the merger, consolidation, or
85+18 other acquisition of control;
86+19 (3) the Director shall have the power to require the
87+20 following information:
88+21 (A) certification by an independent actuary of the
89+22 adequacy of the reserves of the Health Maintenance
90+23 Organization sought to be acquired;
91+24 (B) pro forma financial statements reflecting the
92+25 combined balance sheets of the acquiring company and
93+26 the Health Maintenance Organization sought to be
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143-account the refund period and the immediately preceding 2
144-plan years.
145-The Health Maintenance Organization shall include a
146-statement in the evidence of coverage issued to each enrollee
147-describing the possibility of a refund or additional premium,
148-and upon request of any group or enrollment unit, provide to
149-the group or enrollment unit a description of the method used
150-to calculate (1) the Health Maintenance Organization's
151-profitable experience with respect to the group or enrollment
152-unit and the resulting refund to the group or enrollment unit
153-or (2) the Health Maintenance Organization's unprofitable
154-experience with respect to the group or enrollment unit and
155-the resulting additional premium to be paid by the group or
156-enrollment unit.
157-In no event shall the Illinois Health Maintenance
158-Organization Guaranty Association be liable to pay any
159-contractual obligation of an insolvent organization to pay any
160-refund authorized under this Section.
161-(g) Rulemaking authority to implement Public Act 95-1045,
162-if any, is conditioned on the rules being adopted in
163-accordance with all provisions of the Illinois Administrative
164-Procedure Act and all rules and procedures of the Joint
165-Committee on Administrative Rules; any purported rule not so
166-adopted, for whatever reason, is unauthorized.
167-(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
168-101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
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171-1-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
172-eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
173-102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
174-1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
175-eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
176-102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
177-1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
178-eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
179-Section 15. The Illinois Public Aid Code is amended by
180-changing Section 5-5 as follows:
181-(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
182-Sec. 5-5. Medical services. The Illinois Department, by
183-rule, shall determine the quantity and quality of and the rate
184-of reimbursement for the medical assistance for which payment
185-will be authorized, and the medical services to be provided,
186-which may include all or part of the following: (1) inpatient
187-hospital services; (2) outpatient hospital services; (3) other
188-laboratory and X-ray services; (4) skilled nursing home
189-services; (5) physicians' services whether furnished in the
190-office, the patient's home, a hospital, a skilled nursing
191-home, or elsewhere; (6) medical care, or any other type of
192-remedial care furnished by licensed practitioners; (7) home
193-health care services; (8) private duty nursing service; (9)
194-clinic services; (10) dental services, including prevention
98+
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197-and treatment of periodontal disease and dental caries disease
198-for pregnant individuals, provided by an individual licensed
199-to practice dentistry or dental surgery; for purposes of this
200-item (10), "dental services" means diagnostic, preventive, or
201-corrective procedures provided by or under the supervision of
202-a dentist in the practice of his or her profession; (11)
203-physical therapy and related services; (12) prescribed drugs,
204-dentures, and prosthetic devices; and eyeglasses prescribed by
205-a physician skilled in the diseases of the eye, or by an
206-optometrist, whichever the person may select; (13) other
207-diagnostic, screening, preventive, and rehabilitative
208-services, including to ensure that the individual's need for
209-intervention or treatment of mental disorders or substance use
210-disorders or co-occurring mental health and substance use
211-disorders is determined using a uniform screening, assessment,
212-and evaluation process inclusive of criteria, for children and
213-adults; for purposes of this item (13), a uniform screening,
214-assessment, and evaluation process refers to a process that
215-includes an appropriate evaluation and, as warranted, a
216-referral; "uniform" does not mean the use of a singular
217-instrument, tool, or process that all must utilize; (14)
218-transportation and such other expenses as may be necessary;
219-(15) medical treatment of sexual assault survivors, as defined
220-in Section 1a of the Sexual Assault Survivors Emergency
221-Treatment Act, for injuries sustained as a result of the
222-sexual assault, including examinations and laboratory tests to
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104+1 acquired as of the end of the preceding year and as of
105+2 a date 90 days prior to the acquisition, as well as pro
106+3 forma financial statements reflecting projected
107+4 combined operation for a period of 2 years;
108+5 (C) a pro forma business plan detailing an
109+6 acquiring party's plans with respect to the operation
110+7 of the Health Maintenance Organization sought to be
111+8 acquired for a period of not less than 3 years; and
112+9 (D) such other information as the Director shall
113+10 require.
114+11 (d) The provisions of Article VIII 1/2 of the Illinois
115+12 Insurance Code and this Section 5-3 shall apply to the sale by
116+13 any health maintenance organization of greater than 10% of its
117+14 enrollee population (including without limitation the health
118+15 maintenance organization's right, title, and interest in and
119+16 to its health care certificates).
120+17 (e) In considering any management contract or service
121+18 agreement subject to Section 141.1 of the Illinois Insurance
122+19 Code, the Director (i) shall, in addition to the criteria
123+20 specified in Section 141.2 of the Illinois Insurance Code,
124+21 take into account the effect of the management contract or
125+22 service agreement on the continuation of benefits to enrollees
126+23 and the financial condition of the health maintenance
127+24 organization to be managed or serviced, and (ii) need not take
128+25 into account the effect of the management contract or service
129+26 agreement on competition.
223130
224131
225-discover evidence which may be used in criminal proceedings
226-arising from the sexual assault; (16) the diagnosis and
227-treatment of sickle cell anemia; (16.5) services performed by
228-a chiropractic physician licensed under the Medical Practice
229-Act of 1987 and acting within the scope of his or her license,
230-including, but not limited to, chiropractic manipulative
231-treatment; and (17) any other medical care, and any other type
232-of remedial care recognized under the laws of this State. The
233-term "any other type of remedial care" shall include nursing
234-care and nursing home service for persons who rely on
235-treatment by spiritual means alone through prayer for healing.
236-Notwithstanding any other provision of this Section, a
237-comprehensive tobacco use cessation program that includes
238-purchasing prescription drugs or prescription medical devices
239-approved by the Food and Drug Administration shall be covered
240-under the medical assistance program under this Article for
241-persons who are otherwise eligible for assistance under this
242-Article.
243-Notwithstanding any other provision of this Code,
244-reproductive health care that is otherwise legal in Illinois
245-shall be covered under the medical assistance program for
246-persons who are otherwise eligible for medical assistance
247-under this Article.
248-Notwithstanding any other provision of this Section, all
249-tobacco cessation medications approved by the United States
250-Food and Drug Administration and all individual and group
251132
252133
253-tobacco cessation counseling services and telephone-based
254-counseling services and tobacco cessation medications provided
255-through the Illinois Tobacco Quitline shall be covered under
256-the medical assistance program for persons who are otherwise
257-eligible for assistance under this Article. The Department
258-shall comply with all federal requirements necessary to obtain
259-federal financial participation, as specified in 42 CFR
260-433.15(b)(7), for telephone-based counseling services provided
261-through the Illinois Tobacco Quitline, including, but not
262-limited to: (i) entering into a memorandum of understanding or
263-interagency agreement with the Department of Public Health, as
264-administrator of the Illinois Tobacco Quitline; and (ii)
265-developing a cost allocation plan for Medicaid-allowable
266-Illinois Tobacco Quitline services in accordance with 45 CFR
267-95.507. The Department shall submit the memorandum of
268-understanding or interagency agreement, the cost allocation
269-plan, and all other necessary documentation to the Centers for
270-Medicare and Medicaid Services for review and approval.
271-Coverage under this paragraph shall be contingent upon federal
272-approval.
273-Notwithstanding any other provision of this Code, the
274-Illinois Department may not require, as a condition of payment
275-for any laboratory test authorized under this Article, that a
276-physician's handwritten signature appear on the laboratory
277-test order form. The Illinois Department may, however, impose
278-other appropriate requirements regarding laboratory test order
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281-documentation.
282-Upon receipt of federal approval of an amendment to the
283-Illinois Title XIX State Plan for this purpose, the Department
284-shall authorize the Chicago Public Schools (CPS) to procure a
285-vendor or vendors to manufacture eyeglasses for individuals
286-enrolled in a school within the CPS system. CPS shall ensure
287-that its vendor or vendors are enrolled as providers in the
288-medical assistance program and in any capitated Medicaid
289-managed care entity (MCE) serving individuals enrolled in a
290-school within the CPS system. Under any contract procured
291-under this provision, the vendor or vendors must serve only
292-individuals enrolled in a school within the CPS system. Claims
293-for services provided by CPS's vendor or vendors to recipients
294-of benefits in the medical assistance program under this Code,
295-the Children's Health Insurance Program, or the Covering ALL
296-KIDS Health Insurance Program shall be submitted to the
297-Department or the MCE in which the individual is enrolled for
298-payment and shall be reimbursed at the Department's or the
299-MCE's established rates or rate methodologies for eyeglasses.
300-On and after July 1, 2012, the Department of Healthcare
301-and Family Services may provide the following services to
302-persons eligible for assistance under this Article who are
303-participating in education, training or employment programs
304-operated by the Department of Human Services as successor to
305-the Department of Public Aid:
306-(1) dental services provided by or under the
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140+1 (f) Except for small employer groups as defined in the
141+2 Small Employer Rating, Renewability and Portability Health
142+3 Insurance Act and except for medicare supplement policies as
143+4 defined in Section 363 of the Illinois Insurance Code, a
144+5 Health Maintenance Organization may by contract agree with a
145+6 group or other enrollment unit to effect refunds or charge
146+7 additional premiums under the following terms and conditions:
147+8 (i) the amount of, and other terms and conditions with
148+9 respect to, the refund or additional premium are set forth
149+10 in the group or enrollment unit contract agreed in advance
150+11 of the period for which a refund is to be paid or
151+12 additional premium is to be charged (which period shall
152+13 not be less than one year); and
153+14 (ii) the amount of the refund or additional premium
154+15 shall not exceed 20% of the Health Maintenance
155+16 Organization's profitable or unprofitable experience with
156+17 respect to the group or other enrollment unit for the
157+18 period (and, for purposes of a refund or additional
158+19 premium, the profitable or unprofitable experience shall
159+20 be calculated taking into account a pro rata share of the
160+21 Health Maintenance Organization's administrative and
161+22 marketing expenses, but shall not include any refund to be
162+23 made or additional premium to be paid pursuant to this
163+24 subsection (f)). The Health Maintenance Organization and
164+25 the group or enrollment unit may agree that the profitable
165+26 or unprofitable experience may be calculated taking into
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309-supervision of a dentist; and
310-(2) eyeglasses prescribed by a physician skilled in
311-the diseases of the eye, or by an optometrist, whichever
312-the person may select.
313-On and after July 1, 2018, the Department of Healthcare
314-and Family Services shall provide dental services to any adult
315-who is otherwise eligible for assistance under the medical
316-assistance program. As used in this paragraph, "dental
317-services" means diagnostic, preventative, restorative, or
318-corrective procedures, including procedures and services for
319-the prevention and treatment of periodontal disease and dental
320-caries disease, provided by an individual who is licensed to
321-practice dentistry or dental surgery or who is under the
322-supervision of a dentist in the practice of his or her
323-profession.
324-On and after July 1, 2018, targeted dental services, as
325-set forth in Exhibit D of the Consent Decree entered by the
326-United States District Court for the Northern District of
327-Illinois, Eastern Division, in the matter of Memisovski v.
328-Maram, Case No. 92 C 1982, that are provided to adults under
329-the medical assistance program shall be established at no less
330-than the rates set forth in the "New Rate" column in Exhibit D
331-of the Consent Decree for targeted dental services that are
332-provided to persons under the age of 18 under the medical
333-assistance program.
334-Notwithstanding any other provision of this Code and
335168
336169
337-subject to federal approval, the Department may adopt rules to
338-allow a dentist who is volunteering his or her service at no
339-cost to render dental services through an enrolled
340-not-for-profit health clinic without the dentist personally
341-enrolling as a participating provider in the medical
342-assistance program. A not-for-profit health clinic shall
343-include a public health clinic or Federally Qualified Health
344-Center or other enrolled provider, as determined by the
345-Department, through which dental services covered under this
346-Section are performed. The Department shall establish a
347-process for payment of claims for reimbursement for covered
348-dental services rendered under this provision.
349-On and after January 1, 2022, the Department of Healthcare
350-and Family Services shall administer and regulate a
351-school-based dental program that allows for the out-of-office
352-delivery of preventative dental services in a school setting
353-to children under 19 years of age. The Department shall
354-establish, by rule, guidelines for participation by providers
355-and set requirements for follow-up referral care based on the
356-requirements established in the Dental Office Reference Manual
357-published by the Department that establishes the requirements
358-for dentists participating in the All Kids Dental School
359-Program. Every effort shall be made by the Department when
360-developing the program requirements to consider the different
361-geographic differences of both urban and rural areas of the
362-State for initial treatment and necessary follow-up care. No
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365-provider shall be charged a fee by any unit of local government
366-to participate in the school-based dental program administered
367-by the Department. Nothing in this paragraph shall be
368-construed to limit or preempt a home rule unit's or school
369-district's authority to establish, change, or administer a
370-school-based dental program in addition to, or independent of,
371-the school-based dental program administered by the
372-Department.
373-The Illinois Department, by rule, may distinguish and
374-classify the medical services to be provided only in
375-accordance with the classes of persons designated in Section
376-5-2.
377-The Department of Healthcare and Family Services must
378-provide coverage and reimbursement for amino acid-based
379-elemental formulas, regardless of delivery method, for the
380-diagnosis and treatment of (i) eosinophilic disorders and (ii)
381-short bowel syndrome when the prescribing physician has issued
382-a written order stating that the amino acid-based elemental
383-formula is medically necessary.
384-The Illinois Department shall authorize the provision of,
385-and shall authorize payment for, screening by low-dose
386-mammography for the presence of occult breast cancer for
387-individuals 35 years of age or older who are eligible for
388-medical assistance under this Article, as follows:
389-(A) A baseline mammogram for individuals 35 to 39
390-years of age.
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175+ HB1384 Enrolled - 6 - LRB103 25389 BMS 51735 b
176+1 account the refund period and the immediately preceding 2
177+2 plan years.
178+3 The Health Maintenance Organization shall include a
179+4 statement in the evidence of coverage issued to each enrollee
180+5 describing the possibility of a refund or additional premium,
181+6 and upon request of any group or enrollment unit, provide to
182+7 the group or enrollment unit a description of the method used
183+8 to calculate (1) the Health Maintenance Organization's
184+9 profitable experience with respect to the group or enrollment
185+10 unit and the resulting refund to the group or enrollment unit
186+11 or (2) the Health Maintenance Organization's unprofitable
187+12 experience with respect to the group or enrollment unit and
188+13 the resulting additional premium to be paid by the group or
189+14 enrollment unit.
190+15 In no event shall the Illinois Health Maintenance
191+16 Organization Guaranty Association be liable to pay any
192+17 contractual obligation of an insolvent organization to pay any
193+18 refund authorized under this Section.
194+19 (g) Rulemaking authority to implement Public Act 95-1045,
195+20 if any, is conditioned on the rules being adopted in
196+21 accordance with all provisions of the Illinois Administrative
197+22 Procedure Act and all rules and procedures of the Joint
198+23 Committee on Administrative Rules; any purported rule not so
199+24 adopted, for whatever reason, is unauthorized.
200+25 (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
201+26 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
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393-(B) An annual mammogram for individuals 40 years of
394-age or older.
395-(C) A mammogram at the age and intervals considered
396-medically necessary by the individual's health care
397-provider for individuals under 40 years of age and having
398-a family history of breast cancer, prior personal history
399-of breast cancer, positive genetic testing, or other risk
400-factors.
401-(D) A comprehensive ultrasound screening and MRI of an
402-entire breast or breasts if a mammogram demonstrates
403-heterogeneous or dense breast tissue or when medically
404-necessary as determined by a physician licensed to
405-practice medicine in all of its branches.
406-(E) A screening MRI when medically necessary, as
407-determined by a physician licensed to practice medicine in
408-all of its branches.
409-(F) A diagnostic mammogram when medically necessary,
410-as determined by a physician licensed to practice medicine
411-in all its branches, advanced practice registered nurse,
412-or physician assistant.
413-The Department shall not impose a deductible, coinsurance,
414-copayment, or any other cost-sharing requirement on the
415-coverage provided under this paragraph; except that this
416-sentence does not apply to coverage of diagnostic mammograms
417-to the extent such coverage would disqualify a high-deductible
418-health plan from eligibility for a health savings account
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420205
421-pursuant to Section 223 of the Internal Revenue Code (26
422-U.S.C. 223).
423-All screenings shall include a physical breast exam,
424-instruction on self-examination and information regarding the
425-frequency of self-examination and its value as a preventative
426-tool.
427-For purposes of this Section:
428-"Diagnostic mammogram" means a mammogram obtained using
429-diagnostic mammography.
430-"Diagnostic mammography" means a method of screening that
431-is designed to evaluate an abnormality in a breast, including
432-an abnormality seen or suspected on a screening mammogram or a
433-subjective or objective abnormality otherwise detected in the
434-breast.
435-"Low-dose mammography" means the x-ray examination of the
436-breast using equipment dedicated specifically for mammography,
437-including the x-ray tube, filter, compression device, and
438-image receptor, with an average radiation exposure delivery of
439-less than one rad per breast for 2 views of an average size
440-breast. The term also includes digital mammography and
441-includes breast tomosynthesis.
442-"Breast tomosynthesis" means a radiologic procedure that
443-involves the acquisition of projection images over the
444-stationary breast to produce cross-sectional digital
445-three-dimensional images of the breast.
446-If, at any time, the Secretary of the United States
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448209
449-Department of Health and Human Services, or its successor
450-agency, promulgates rules or regulations to be published in
451-the Federal Register or publishes a comment in the Federal
452-Register or issues an opinion, guidance, or other action that
453-would require the State, pursuant to any provision of the
454-Patient Protection and Affordable Care Act (Public Law
455-111-148), including, but not limited to, 42 U.S.C.
456-18031(d)(3)(B) or any successor provision, to defray the cost
457-of any coverage for breast tomosynthesis outlined in this
458-paragraph, then the requirement that an insurer cover breast
459-tomosynthesis is inoperative other than any such coverage
460-authorized under Section 1902 of the Social Security Act, 42
461-U.S.C. 1396a, and the State shall not assume any obligation
462-for the cost of coverage for breast tomosynthesis set forth in
463-this paragraph.
464-On and after January 1, 2016, the Department shall ensure
465-that all networks of care for adult clients of the Department
466-include access to at least one breast imaging Center of
467-Imaging Excellence as certified by the American College of
468-Radiology.
469-On and after January 1, 2012, providers participating in a
470-quality improvement program approved by the Department shall
471-be reimbursed for screening and diagnostic mammography at the
472-same rate as the Medicare program's rates, including the
473-increased reimbursement for digital mammography and, after
474-January 1, 2023 (the effective date of Public Act 102-1018)
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211+ HB1384 Enrolled - 7 - LRB103 25389 BMS 51735 b
212+1 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
213+2 eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
214+3 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
215+4 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
216+5 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
217+6 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
218+7 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
219+8 eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
220+9 Section 15. The Illinois Public Aid Code is amended by
221+10 changing Section 5-5 as follows:
222+11 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
223+12 Sec. 5-5. Medical services. The Illinois Department, by
224+13 rule, shall determine the quantity and quality of and the rate
225+14 of reimbursement for the medical assistance for which payment
226+15 will be authorized, and the medical services to be provided,
227+16 which may include all or part of the following: (1) inpatient
228+17 hospital services; (2) outpatient hospital services; (3) other
229+18 laboratory and X-ray services; (4) skilled nursing home
230+19 services; (5) physicians' services whether furnished in the
231+20 office, the patient's home, a hospital, a skilled nursing
232+21 home, or elsewhere; (6) medical care, or any other type of
233+22 remedial care furnished by licensed practitioners; (7) home
234+23 health care services; (8) private duty nursing service; (9)
235+24 clinic services; (10) dental services, including prevention
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477-this amendatory Act of the 102nd General Assembly, breast
478-tomosynthesis.
479-The Department shall convene an expert panel including
480-representatives of hospitals, free-standing mammography
481-facilities, and doctors, including radiologists, to establish
482-quality standards for mammography.
483-On and after January 1, 2017, providers participating in a
484-breast cancer treatment quality improvement program approved
485-by the Department shall be reimbursed for breast cancer
486-treatment at a rate that is no lower than 95% of the Medicare
487-program's rates for the data elements included in the breast
488-cancer treatment quality program.
489-The Department shall convene an expert panel, including
490-representatives of hospitals, free-standing breast cancer
491-treatment centers, breast cancer quality organizations, and
492-doctors, including breast surgeons, reconstructive breast
493-surgeons, oncologists, and primary care providers to establish
494-quality standards for breast cancer treatment.
495-Subject to federal approval, the Department shall
496-establish a rate methodology for mammography at federally
497-qualified health centers and other encounter-rate clinics.
498-These clinics or centers may also collaborate with other
499-hospital-based mammography facilities. By January 1, 2016, the
500-Department shall report to the General Assembly on the status
501-of the provision set forth in this paragraph.
502-The Department shall establish a methodology to remind
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505-individuals who are age-appropriate for screening mammography,
506-but who have not received a mammogram within the previous 18
507-months, of the importance and benefit of screening
508-mammography. The Department shall work with experts in breast
509-cancer outreach and patient navigation to optimize these
510-reminders and shall establish a methodology for evaluating
511-their effectiveness and modifying the methodology based on the
512-evaluation.
513-The Department shall establish a performance goal for
514-primary care providers with respect to their female patients
515-over age 40 receiving an annual mammogram. This performance
516-goal shall be used to provide additional reimbursement in the
517-form of a quality performance bonus to primary care providers
518-who meet that goal.
519-The Department shall devise a means of case-managing or
520-patient navigation for beneficiaries diagnosed with breast
521-cancer. This program shall initially operate as a pilot
522-program in areas of the State with the highest incidence of
523-mortality related to breast cancer. At least one pilot program
524-site shall be in the metropolitan Chicago area and at least one
525-site shall be outside the metropolitan Chicago area. On or
526-after July 1, 2016, the pilot program shall be expanded to
527-include one site in western Illinois, one site in southern
528-Illinois, one site in central Illinois, and 4 sites within
529-metropolitan Chicago. An evaluation of the pilot program shall
530-be carried out measuring health outcomes and cost of care for
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533-those served by the pilot program compared to similarly
534-situated patients who are not served by the pilot program.
535-The Department shall require all networks of care to
536-develop a means either internally or by contract with experts
537-in navigation and community outreach to navigate cancer
538-patients to comprehensive care in a timely fashion. The
539-Department shall require all networks of care to include
540-access for patients diagnosed with cancer to at least one
541-academic commission on cancer-accredited cancer program as an
542-in-network covered benefit.
543-The Department shall provide coverage and reimbursement
544-for a human papillomavirus (HPV) vaccine that is approved for
545-marketing by the federal Food and Drug Administration for all
546-persons between the ages of 9 and 45 and persons of the age of
547-46 and above who have been diagnosed with cervical dysplasia
548-with a high risk of recurrence or progression. The Department
549-shall disallow any preauthorization requirements for the
550-administration of the human papillomavirus (HPV) vaccine.
551-On or after July 1, 2022, individuals who are otherwise
552-eligible for medical assistance under this Article shall
553-receive coverage for perinatal depression screenings for the
554-12-month period beginning on the last day of their pregnancy.
555-Medical assistance coverage under this paragraph shall be
556-conditioned on the use of a screening instrument approved by
557-the Department.
558-Any medical or health care provider shall immediately
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246+1 and treatment of periodontal disease and dental caries disease
247+2 for pregnant individuals, provided by an individual licensed
248+3 to practice dentistry or dental surgery; for purposes of this
249+4 item (10), "dental services" means diagnostic, preventive, or
250+5 corrective procedures provided by or under the supervision of
251+6 a dentist in the practice of his or her profession; (11)
252+7 physical therapy and related services; (12) prescribed drugs,
253+8 dentures, and prosthetic devices; and eyeglasses prescribed by
254+9 a physician skilled in the diseases of the eye, or by an
255+10 optometrist, whichever the person may select; (13) other
256+11 diagnostic, screening, preventive, and rehabilitative
257+12 services, including to ensure that the individual's need for
258+13 intervention or treatment of mental disorders or substance use
259+14 disorders or co-occurring mental health and substance use
260+15 disorders is determined using a uniform screening, assessment,
261+16 and evaluation process inclusive of criteria, for children and
262+17 adults; for purposes of this item (13), a uniform screening,
263+18 assessment, and evaluation process refers to a process that
264+19 includes an appropriate evaluation and, as warranted, a
265+20 referral; "uniform" does not mean the use of a singular
266+21 instrument, tool, or process that all must utilize; (14)
267+22 transportation and such other expenses as may be necessary;
268+23 (15) medical treatment of sexual assault survivors, as defined
269+24 in Section 1a of the Sexual Assault Survivors Emergency
270+25 Treatment Act, for injuries sustained as a result of the
271+26 sexual assault, including examinations and laboratory tests to
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560273
561-recommend, to any pregnant individual who is being provided
562-prenatal services and is suspected of having a substance use
563-disorder as defined in the Substance Use Disorder Act,
564-referral to a local substance use disorder treatment program
565-licensed by the Department of Human Services or to a licensed
566-hospital which provides substance abuse treatment services.
567-The Department of Healthcare and Family Services shall assure
568-coverage for the cost of treatment of the drug abuse or
569-addiction for pregnant recipients in accordance with the
570-Illinois Medicaid Program in conjunction with the Department
571-of Human Services.
572-All medical providers providing medical assistance to
573-pregnant individuals under this Code shall receive information
574-from the Department on the availability of services under any
575-program providing case management services for addicted
576-individuals, including information on appropriate referrals
577-for other social services that may be needed by addicted
578-individuals in addition to treatment for addiction.
579-The Illinois Department, in cooperation with the
580-Departments of Human Services (as successor to the Department
581-of Alcoholism and Substance Abuse) and Public Health, through
582-a public awareness campaign, may provide information
583-concerning treatment for alcoholism and drug abuse and
584-addiction, prenatal health care, and other pertinent programs
585-directed at reducing the number of drug-affected infants born
586-to recipients of medical assistance.
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588275
589-Neither the Department of Healthcare and Family Services
590-nor the Department of Human Services shall sanction the
591-recipient solely on the basis of the recipient's substance
592-abuse.
593-The Illinois Department shall establish such regulations
594-governing the dispensing of health services under this Article
595-as it shall deem appropriate. The Department should seek the
596-advice of formal professional advisory committees appointed by
597-the Director of the Illinois Department for the purpose of
598-providing regular advice on policy and administrative matters,
599-information dissemination and educational activities for
600-medical and health care providers, and consistency in
601-procedures to the Illinois Department.
602-The Illinois Department may develop and contract with
603-Partnerships of medical providers to arrange medical services
604-for persons eligible under Section 5-2 of this Code.
605-Implementation of this Section may be by demonstration
606-projects in certain geographic areas. The Partnership shall be
607-represented by a sponsor organization. The Department, by
608-rule, shall develop qualifications for sponsors of
609-Partnerships. Nothing in this Section shall be construed to
610-require that the sponsor organization be a medical
611-organization.
612-The sponsor must negotiate formal written contracts with
613-medical providers for physician services, inpatient and
614-outpatient hospital care, home health services, treatment for
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616279
617-alcoholism and substance abuse, and other services determined
618-necessary by the Illinois Department by rule for delivery by
619-Partnerships. Physician services must include prenatal and
620-obstetrical care. The Illinois Department shall reimburse
621-medical services delivered by Partnership providers to clients
622-in target areas according to provisions of this Article and
623-the Illinois Health Finance Reform Act, except that:
624-(1) Physicians participating in a Partnership and
625-providing certain services, which shall be determined by
626-the Illinois Department, to persons in areas covered by
627-the Partnership may receive an additional surcharge for
628-such services.
629-(2) The Department may elect to consider and negotiate
630-financial incentives to encourage the development of
631-Partnerships and the efficient delivery of medical care.
632-(3) Persons receiving medical services through
633-Partnerships may receive medical and case management
634-services above the level usually offered through the
635-medical assistance program.
636-Medical providers shall be required to meet certain
637-qualifications to participate in Partnerships to ensure the
638-delivery of high quality medical services. These
639-qualifications shall be determined by rule of the Illinois
640-Department and may be higher than qualifications for
641-participation in the medical assistance program. Partnership
642-sponsors may prescribe reasonable additional qualifications
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282+1 discover evidence which may be used in criminal proceedings
283+2 arising from the sexual assault; (16) the diagnosis and
284+3 treatment of sickle cell anemia; (16.5) services performed by
285+4 a chiropractic physician licensed under the Medical Practice
286+5 Act of 1987 and acting within the scope of his or her license,
287+6 including, but not limited to, chiropractic manipulative
288+7 treatment; and (17) any other medical care, and any other type
289+8 of remedial care recognized under the laws of this State. The
290+9 term "any other type of remedial care" shall include nursing
291+10 care and nursing home service for persons who rely on
292+11 treatment by spiritual means alone through prayer for healing.
293+12 Notwithstanding any other provision of this Section, a
294+13 comprehensive tobacco use cessation program that includes
295+14 purchasing prescription drugs or prescription medical devices
296+15 approved by the Food and Drug Administration shall be covered
297+16 under the medical assistance program under this Article for
298+17 persons who are otherwise eligible for assistance under this
299+18 Article.
300+19 Notwithstanding any other provision of this Code,
301+20 reproductive health care that is otherwise legal in Illinois
302+21 shall be covered under the medical assistance program for
303+22 persons who are otherwise eligible for medical assistance
304+23 under this Article.
305+24 Notwithstanding any other provision of this Section, all
306+25 tobacco cessation medications approved by the United States
307+26 Food and Drug Administration and all individual and group
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644309
645-for participation by medical providers, only with the prior
646-written approval of the Illinois Department.
647-Nothing in this Section shall limit the free choice of
648-practitioners, hospitals, and other providers of medical
649-services by clients. In order to ensure patient freedom of
650-choice, the Illinois Department shall immediately promulgate
651-all rules and take all other necessary actions so that
652-provided services may be accessed from therapeutically
653-certified optometrists to the full extent of the Illinois
654-Optometric Practice Act of 1987 without discriminating between
655-service providers.
656-The Department shall apply for a waiver from the United
657-States Health Care Financing Administration to allow for the
658-implementation of Partnerships under this Section.
659-The Illinois Department shall require health care
660-providers to maintain records that document the medical care
661-and services provided to recipients of Medical Assistance
662-under this Article. Such records must be retained for a period
663-of not less than 6 years from the date of service or as
664-provided by applicable State law, whichever period is longer,
665-except that if an audit is initiated within the required
666-retention period then the records must be retained until the
667-audit is completed and every exception is resolved. The
668-Illinois Department shall require health care providers to
669-make available, when authorized by the patient, in writing,
670-the medical records in a timely fashion to other health care
671310
672311
673-providers who are treating or serving persons eligible for
674-Medical Assistance under this Article. All dispensers of
675-medical services shall be required to maintain and retain
676-business and professional records sufficient to fully and
677-accurately document the nature, scope, details and receipt of
678-the health care provided to persons eligible for medical
679-assistance under this Code, in accordance with regulations
680-promulgated by the Illinois Department. The rules and
681-regulations shall require that proof of the receipt of
682-prescription drugs, dentures, prosthetic devices and
683-eyeglasses by eligible persons under this Section accompany
684-each claim for reimbursement submitted by the dispenser of
685-such medical services. No such claims for reimbursement shall
686-be approved for payment by the Illinois Department without
687-such proof of receipt, unless the Illinois Department shall
688-have put into effect and shall be operating a system of
689-post-payment audit and review which shall, on a sampling
690-basis, be deemed adequate by the Illinois Department to assure
691-that such drugs, dentures, prosthetic devices and eyeglasses
692-for which payment is being made are actually being received by
693-eligible recipients. Within 90 days after September 16, 1984
694-(the effective date of Public Act 83-1439), the Illinois
695-Department shall establish a current list of acquisition costs
696-for all prosthetic devices and any other items recognized as
697-medical equipment and supplies reimbursable under this Article
698-and shall update such list on a quarterly basis, except that
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701-the acquisition costs of all prescription drugs shall be
702-updated no less frequently than every 30 days as required by
703-Section 5-5.12.
704-Notwithstanding any other law to the contrary, the
705-Illinois Department shall, within 365 days after July 22, 2013
706-(the effective date of Public Act 98-104), establish
707-procedures to permit skilled care facilities licensed under
708-the Nursing Home Care Act to submit monthly billing claims for
709-reimbursement purposes. Following development of these
710-procedures, the Department shall, by July 1, 2016, test the
711-viability of the new system and implement any necessary
712-operational or structural changes to its information
713-technology platforms in order to allow for the direct
714-acceptance and payment of nursing home claims.
715-Notwithstanding any other law to the contrary, the
716-Illinois Department shall, within 365 days after August 15,
717-2014 (the effective date of Public Act 98-963), establish
718-procedures to permit ID/DD facilities licensed under the ID/DD
719-Community Care Act and MC/DD facilities licensed under the
720-MC/DD Act to submit monthly billing claims for reimbursement
721-purposes. Following development of these procedures, the
722-Department shall have an additional 365 days to test the
723-viability of the new system and to ensure that any necessary
724-operational or structural changes to its information
725-technology platforms are implemented.
726-The Illinois Department shall require all dispensers of
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318+1 tobacco cessation counseling services and telephone-based
319+2 counseling services and tobacco cessation medications provided
320+3 through the Illinois Tobacco Quitline shall be covered under
321+4 the medical assistance program for persons who are otherwise
322+5 eligible for assistance under this Article. The Department
323+6 shall comply with all federal requirements necessary to obtain
324+7 federal financial participation, as specified in 42 CFR
325+8 433.15(b)(7), for telephone-based counseling services provided
326+9 through the Illinois Tobacco Quitline, including, but not
327+10 limited to: (i) entering into a memorandum of understanding or
328+11 interagency agreement with the Department of Public Health, as
329+12 administrator of the Illinois Tobacco Quitline; and (ii)
330+13 developing a cost allocation plan for Medicaid-allowable
331+14 Illinois Tobacco Quitline services in accordance with 45 CFR
332+15 95.507. The Department shall submit the memorandum of
333+16 understanding or interagency agreement, the cost allocation
334+17 plan, and all other necessary documentation to the Centers for
335+18 Medicare and Medicaid Services for review and approval.
336+19 Coverage under this paragraph shall be contingent upon federal
337+20 approval.
338+21 Notwithstanding any other provision of this Code, the
339+22 Illinois Department may not require, as a condition of payment
340+23 for any laboratory test authorized under this Article, that a
341+24 physician's handwritten signature appear on the laboratory
342+25 test order form. The Illinois Department may, however, impose
343+26 other appropriate requirements regarding laboratory test order
727344
728345
729-medical services, other than an individual practitioner or
730-group of practitioners, desiring to participate in the Medical
731-Assistance program established under this Article to disclose
732-all financial, beneficial, ownership, equity, surety or other
733-interests in any and all firms, corporations, partnerships,
734-associations, business enterprises, joint ventures, agencies,
735-institutions or other legal entities providing any form of
736-health care services in this State under this Article.
737-The Illinois Department may require that all dispensers of
738-medical services desiring to participate in the medical
739-assistance program established under this Article disclose,
740-under such terms and conditions as the Illinois Department may
741-by rule establish, all inquiries from clients and attorneys
742-regarding medical bills paid by the Illinois Department, which
743-inquiries could indicate potential existence of claims or
744-liens for the Illinois Department.
745-Enrollment of a vendor shall be subject to a provisional
746-period and shall be conditional for one year. During the
747-period of conditional enrollment, the Department may terminate
748-the vendor's eligibility to participate in, or may disenroll
749-the vendor from, the medical assistance program without cause.
750-Unless otherwise specified, such termination of eligibility or
751-disenrollment is not subject to the Department's hearing
752-process. However, a disenrolled vendor may reapply without
753-penalty.
754-The Department has the discretion to limit the conditional
755346
756347
757-enrollment period for vendors based upon the category of risk
758-of the vendor.
759-Prior to enrollment and during the conditional enrollment
760-period in the medical assistance program, all vendors shall be
761-subject to enhanced oversight, screening, and review based on
762-the risk of fraud, waste, and abuse that is posed by the
763-category of risk of the vendor. The Illinois Department shall
764-establish the procedures for oversight, screening, and review,
765-which may include, but need not be limited to: criminal and
766-financial background checks; fingerprinting; license,
767-certification, and authorization verifications; unscheduled or
768-unannounced site visits; database checks; prepayment audit
769-reviews; audits; payment caps; payment suspensions; and other
770-screening as required by federal or State law.
771-The Department shall define or specify the following: (i)
772-by provider notice, the "category of risk of the vendor" for
773-each type of vendor, which shall take into account the level of
774-screening applicable to a particular category of vendor under
775-federal law and regulations; (ii) by rule or provider notice,
776-the maximum length of the conditional enrollment period for
777-each category of risk of the vendor; and (iii) by rule, the
778-hearing rights, if any, afforded to a vendor in each category
779-of risk of the vendor that is terminated or disenrolled during
780-the conditional enrollment period.
781-To be eligible for payment consideration, a vendor's
782-payment claim or bill, either as an initial claim or as a
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784351
785-resubmitted claim following prior rejection, must be received
786-by the Illinois Department, or its fiscal intermediary, no
787-later than 180 days after the latest date on the claim on which
788-medical goods or services were provided, with the following
789-exceptions:
790-(1) In the case of a provider whose enrollment is in
791-process by the Illinois Department, the 180-day period
792-shall not begin until the date on the written notice from
793-the Illinois Department that the provider enrollment is
794-complete.
795-(2) In the case of errors attributable to the Illinois
796-Department or any of its claims processing intermediaries
797-which result in an inability to receive, process, or
798-adjudicate a claim, the 180-day period shall not begin
799-until the provider has been notified of the error.
800-(3) In the case of a provider for whom the Illinois
801-Department initiates the monthly billing process.
802-(4) In the case of a provider operated by a unit of
803-local government with a population exceeding 3,000,000
804-when local government funds finance federal participation
805-for claims payments.
806-For claims for services rendered during a period for which
807-a recipient received retroactive eligibility, claims must be
808-filed within 180 days after the Department determines the
809-applicant is eligible. For claims for which the Illinois
810-Department is not the primary payer, claims must be submitted
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354+1 documentation.
355+2 Upon receipt of federal approval of an amendment to the
356+3 Illinois Title XIX State Plan for this purpose, the Department
357+4 shall authorize the Chicago Public Schools (CPS) to procure a
358+5 vendor or vendors to manufacture eyeglasses for individuals
359+6 enrolled in a school within the CPS system. CPS shall ensure
360+7 that its vendor or vendors are enrolled as providers in the
361+8 medical assistance program and in any capitated Medicaid
362+9 managed care entity (MCE) serving individuals enrolled in a
363+10 school within the CPS system. Under any contract procured
364+11 under this provision, the vendor or vendors must serve only
365+12 individuals enrolled in a school within the CPS system. Claims
366+13 for services provided by CPS's vendor or vendors to recipients
367+14 of benefits in the medical assistance program under this Code,
368+15 the Children's Health Insurance Program, or the Covering ALL
369+16 KIDS Health Insurance Program shall be submitted to the
370+17 Department or the MCE in which the individual is enrolled for
371+18 payment and shall be reimbursed at the Department's or the
372+19 MCE's established rates or rate methodologies for eyeglasses.
373+20 On and after July 1, 2012, the Department of Healthcare
374+21 and Family Services may provide the following services to
375+22 persons eligible for assistance under this Article who are
376+23 participating in education, training or employment programs
377+24 operated by the Department of Human Services as successor to
378+25 the Department of Public Aid:
379+26 (1) dental services provided by or under the
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813-to the Illinois Department within 180 days after the final
814-adjudication by the primary payer.
815-In the case of long term care facilities, within 120
816-calendar days of receipt by the facility of required
817-prescreening information, new admissions with associated
818-admission documents shall be submitted through the Medical
819-Electronic Data Interchange (MEDI) or the Recipient
820-Eligibility Verification (REV) System or shall be submitted
821-directly to the Department of Human Services using required
822-admission forms. Effective September 1, 2014, admission
823-documents, including all prescreening information, must be
824-submitted through MEDI or REV. Confirmation numbers assigned
825-to an accepted transaction shall be retained by a facility to
826-verify timely submittal. Once an admission transaction has
827-been completed, all resubmitted claims following prior
828-rejection are subject to receipt no later than 180 days after
829-the admission transaction has been completed.
830-Claims that are not submitted and received in compliance
831-with the foregoing requirements shall not be eligible for
832-payment under the medical assistance program, and the State
833-shall have no liability for payment of those claims.
834-To the extent consistent with applicable information and
835-privacy, security, and disclosure laws, State and federal
836-agencies and departments shall provide the Illinois Department
837-access to confidential and other information and data
838-necessary to perform eligibility and payment verifications and
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841-other Illinois Department functions. This includes, but is not
842-limited to: information pertaining to licensure;
843-certification; earnings; immigration status; citizenship; wage
844-reporting; unearned and earned income; pension income;
845-employment; supplemental security income; social security
846-numbers; National Provider Identifier (NPI) numbers; the
847-National Practitioner Data Bank (NPDB); program and agency
848-exclusions; taxpayer identification numbers; tax delinquency;
849-corporate information; and death records.
850-The Illinois Department shall enter into agreements with
851-State agencies and departments, and is authorized to enter
852-into agreements with federal agencies and departments, under
853-which such agencies and departments shall share data necessary
854-for medical assistance program integrity functions and
855-oversight. The Illinois Department shall develop, in
856-cooperation with other State departments and agencies, and in
857-compliance with applicable federal laws and regulations,
858-appropriate and effective methods to share such data. At a
859-minimum, and to the extent necessary to provide data sharing,
860-the Illinois Department shall enter into agreements with State
861-agencies and departments, and is authorized to enter into
862-agreements with federal agencies and departments, including,
863-but not limited to: the Secretary of State; the Department of
864-Revenue; the Department of Public Health; the Department of
865-Human Services; and the Department of Financial and
866-Professional Regulation.
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869-Beginning in fiscal year 2013, the Illinois Department
870-shall set forth a request for information to identify the
871-benefits of a pre-payment, post-adjudication, and post-edit
872-claims system with the goals of streamlining claims processing
873-and provider reimbursement, reducing the number of pending or
874-rejected claims, and helping to ensure a more transparent
875-adjudication process through the utilization of: (i) provider
876-data verification and provider screening technology; and (ii)
877-clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
878-or post-adjudicated predictive modeling with an integrated
879-case management system with link analysis. Such a request for
880-information shall not be considered as a request for proposal
881-or as an obligation on the part of the Illinois Department to
882-take any action or acquire any products or services.
883-The Illinois Department shall establish policies,
884-procedures, standards and criteria by rule for the
885-acquisition, repair and replacement of orthotic and prosthetic
886-devices and durable medical equipment. Such rules shall
887-provide, but not be limited to, the following services: (1)
888-immediate repair or replacement of such devices by recipients;
889-and (2) rental, lease, purchase or lease-purchase of durable
890-medical equipment in a cost-effective manner, taking into
891-consideration the recipient's medical prognosis, the extent of
892-the recipient's needs, and the requirements and costs for
893-maintaining such equipment. Subject to prior approval, such
894-rules shall enable a recipient to temporarily acquire and use
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390+1 supervision of a dentist; and
391+2 (2) eyeglasses prescribed by a physician skilled in
392+3 the diseases of the eye, or by an optometrist, whichever
393+4 the person may select.
394+5 On and after July 1, 2018, the Department of Healthcare
395+6 and Family Services shall provide dental services to any adult
396+7 who is otherwise eligible for assistance under the medical
397+8 assistance program. As used in this paragraph, "dental
398+9 services" means diagnostic, preventative, restorative, or
399+10 corrective procedures, including procedures and services for
400+11 the prevention and treatment of periodontal disease and dental
401+12 caries disease, provided by an individual who is licensed to
402+13 practice dentistry or dental surgery or who is under the
403+14 supervision of a dentist in the practice of his or her
404+15 profession.
405+16 On and after July 1, 2018, targeted dental services, as
406+17 set forth in Exhibit D of the Consent Decree entered by the
407+18 United States District Court for the Northern District of
408+19 Illinois, Eastern Division, in the matter of Memisovski v.
409+20 Maram, Case No. 92 C 1982, that are provided to adults under
410+21 the medical assistance program shall be established at no less
411+22 than the rates set forth in the "New Rate" column in Exhibit D
412+23 of the Consent Decree for targeted dental services that are
413+24 provided to persons under the age of 18 under the medical
414+25 assistance program.
415+26 Notwithstanding any other provision of this Code and
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897-alternative or substitute devices or equipment pending repairs
898-or replacements of any device or equipment previously
899-authorized for such recipient by the Department.
900-Notwithstanding any provision of Section 5-5f to the contrary,
901-the Department may, by rule, exempt certain replacement
902-wheelchair parts from prior approval and, for wheelchairs,
903-wheelchair parts, wheelchair accessories, and related seating
904-and positioning items, determine the wholesale price by
905-methods other than actual acquisition costs.
906-The Department shall require, by rule, all providers of
907-durable medical equipment to be accredited by an accreditation
908-organization approved by the federal Centers for Medicare and
909-Medicaid Services and recognized by the Department in order to
910-bill the Department for providing durable medical equipment to
911-recipients. No later than 15 months after the effective date
912-of the rule adopted pursuant to this paragraph, all providers
913-must meet the accreditation requirement.
914-In order to promote environmental responsibility, meet the
915-needs of recipients and enrollees, and achieve significant
916-cost savings, the Department, or a managed care organization
917-under contract with the Department, may provide recipients or
918-managed care enrollees who have a prescription or Certificate
919-of Medical Necessity access to refurbished durable medical
920-equipment under this Section (excluding prosthetic and
921-orthotic devices as defined in the Orthotics, Prosthetics, and
922-Pedorthics Practice Act and complex rehabilitation technology
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924419
925-products and associated services) through the State's
926-assistive technology program's reutilization program, using
927-staff with the Assistive Technology Professional (ATP)
928-Certification if the refurbished durable medical equipment:
929-(i) is available; (ii) is less expensive, including shipping
930-costs, than new durable medical equipment of the same type;
931-(iii) is able to withstand at least 3 years of use; (iv) is
932-cleaned, disinfected, sterilized, and safe in accordance with
933-federal Food and Drug Administration regulations and guidance
934-governing the reprocessing of medical devices in health care
935-settings; and (v) equally meets the needs of the recipient or
936-enrollee. The reutilization program shall confirm that the
937-recipient or enrollee is not already in receipt of the same or
938-similar equipment from another service provider, and that the
939-refurbished durable medical equipment equally meets the needs
940-of the recipient or enrollee. Nothing in this paragraph shall
941-be construed to limit recipient or enrollee choice to obtain
942-new durable medical equipment or place any additional prior
943-authorization conditions on enrollees of managed care
944-organizations.
945-The Department shall execute, relative to the nursing home
946-prescreening project, written inter-agency agreements with the
947-Department of Human Services and the Department on Aging, to
948-effect the following: (i) intake procedures and common
949-eligibility criteria for those persons who are receiving
950-non-institutional services; and (ii) the establishment and
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953-development of non-institutional services in areas of the
954-State where they are not currently available or are
955-undeveloped; and (iii) notwithstanding any other provision of
956-law, subject to federal approval, on and after July 1, 2012, an
957-increase in the determination of need (DON) scores from 29 to
958-37 for applicants for institutional and home and
959-community-based long term care; if and only if federal
960-approval is not granted, the Department may, in conjunction
961-with other affected agencies, implement utilization controls
962-or changes in benefit packages to effectuate a similar savings
963-amount for this population; and (iv) no later than July 1,
964-2013, minimum level of care eligibility criteria for
965-institutional and home and community-based long term care; and
966-(v) no later than October 1, 2013, establish procedures to
967-permit long term care providers access to eligibility scores
968-for individuals with an admission date who are seeking or
969-receiving services from the long term care provider. In order
970-to select the minimum level of care eligibility criteria, the
971-Governor shall establish a workgroup that includes affected
972-agency representatives and stakeholders representing the
973-institutional and home and community-based long term care
974-interests. This Section shall not restrict the Department from
975-implementing lower level of care eligibility criteria for
976-community-based services in circumstances where federal
977-approval has been granted.
978-The Illinois Department shall develop and operate, in
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426+1 subject to federal approval, the Department may adopt rules to
427+2 allow a dentist who is volunteering his or her service at no
428+3 cost to render dental services through an enrolled
429+4 not-for-profit health clinic without the dentist personally
430+5 enrolling as a participating provider in the medical
431+6 assistance program. A not-for-profit health clinic shall
432+7 include a public health clinic or Federally Qualified Health
433+8 Center or other enrolled provider, as determined by the
434+9 Department, through which dental services covered under this
435+10 Section are performed. The Department shall establish a
436+11 process for payment of claims for reimbursement for covered
437+12 dental services rendered under this provision.
438+13 On and after January 1, 2022, the Department of Healthcare
439+14 and Family Services shall administer and regulate a
440+15 school-based dental program that allows for the out-of-office
441+16 delivery of preventative dental services in a school setting
442+17 to children under 19 years of age. The Department shall
443+18 establish, by rule, guidelines for participation by providers
444+19 and set requirements for follow-up referral care based on the
445+20 requirements established in the Dental Office Reference Manual
446+21 published by the Department that establishes the requirements
447+22 for dentists participating in the All Kids Dental School
448+23 Program. Every effort shall be made by the Department when
449+24 developing the program requirements to consider the different
450+25 geographic differences of both urban and rural areas of the
451+26 State for initial treatment and necessary follow-up care. No
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981-cooperation with other State Departments and agencies and in
982-compliance with applicable federal laws and regulations,
983-appropriate and effective systems of health care evaluation
984-and programs for monitoring of utilization of health care
985-services and facilities, as it affects persons eligible for
986-medical assistance under this Code.
987-The Illinois Department shall report annually to the
988-General Assembly, no later than the second Friday in April of
989-1979 and each year thereafter, in regard to:
990-(a) actual statistics and trends in utilization of
991-medical services by public aid recipients;
992-(b) actual statistics and trends in the provision of
993-the various medical services by medical vendors;
994-(c) current rate structures and proposed changes in
995-those rate structures for the various medical vendors; and
996-(d) efforts at utilization review and control by the
997-Illinois Department.
998-The period covered by each report shall be the 3 years
999-ending on the June 30 prior to the report. The report shall
1000-include suggested legislation for consideration by the General
1001-Assembly. The requirement for reporting to the General
1002-Assembly shall be satisfied by filing copies of the report as
1003-required by Section 3.1 of the General Assembly Organization
1004-Act, and filing such additional copies with the State
1005-Government Report Distribution Center for the General Assembly
1006-as is required under paragraph (t) of Section 7 of the State
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1009-Library Act.
1010-Rulemaking authority to implement Public Act 95-1045, if
1011-any, is conditioned on the rules being adopted in accordance
1012-with all provisions of the Illinois Administrative Procedure
1013-Act and all rules and procedures of the Joint Committee on
1014-Administrative Rules; any purported rule not so adopted, for
1015-whatever reason, is unauthorized.
1016-On and after July 1, 2012, the Department shall reduce any
1017-rate of reimbursement for services or other payments or alter
1018-any methodologies authorized by this Code to reduce any rate
1019-of reimbursement for services or other payments in accordance
1020-with Section 5-5e.
1021-Because kidney transplantation can be an appropriate,
1022-cost-effective alternative to renal dialysis when medically
1023-necessary and notwithstanding the provisions of Section 1-11
1024-of this Code, beginning October 1, 2014, the Department shall
1025-cover kidney transplantation for noncitizens with end-stage
1026-renal disease who are not eligible for comprehensive medical
1027-benefits, who meet the residency requirements of Section 5-3
1028-of this Code, and who would otherwise meet the financial
1029-requirements of the appropriate class of eligible persons
1030-under Section 5-2 of this Code. To qualify for coverage of
1031-kidney transplantation, such person must be receiving
1032-emergency renal dialysis services covered by the Department.
1033-Providers under this Section shall be prior approved and
1034-certified by the Department to perform kidney transplantation
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1037-and the services under this Section shall be limited to
1038-services associated with kidney transplantation.
1039-Notwithstanding any other provision of this Code to the
1040-contrary, on or after July 1, 2015, all FDA approved forms of
1041-medication assisted treatment prescribed for the treatment of
1042-alcohol dependence or treatment of opioid dependence shall be
1043-covered under both fee for service and managed care medical
1044-assistance programs for persons who are otherwise eligible for
1045-medical assistance under this Article and shall not be subject
1046-to any (1) utilization control, other than those established
1047-under the American Society of Addiction Medicine patient
1048-placement criteria, (2) prior authorization mandate, or (3)
1049-lifetime restriction limit mandate.
1050-On or after July 1, 2015, opioid antagonists prescribed
1051-for the treatment of an opioid overdose, including the
1052-medication product, administration devices, and any pharmacy
1053-fees or hospital fees related to the dispensing, distribution,
1054-and administration of the opioid antagonist, shall be covered
1055-under the medical assistance program for persons who are
1056-otherwise eligible for medical assistance under this Article.
1057-As used in this Section, "opioid antagonist" means a drug that
1058-binds to opioid receptors and blocks or inhibits the effect of
1059-opioids acting on those receptors, including, but not limited
1060-to, naloxone hydrochloride or any other similarly acting drug
1061-approved by the U.S. Food and Drug Administration. The
1062-Department shall not impose a copayment on the coverage
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462+1 provider shall be charged a fee by any unit of local government
463+2 to participate in the school-based dental program administered
464+3 by the Department. Nothing in this paragraph shall be
465+4 construed to limit or preempt a home rule unit's or school
466+5 district's authority to establish, change, or administer a
467+6 school-based dental program in addition to, or independent of,
468+7 the school-based dental program administered by the
469+8 Department.
470+9 The Illinois Department, by rule, may distinguish and
471+10 classify the medical services to be provided only in
472+11 accordance with the classes of persons designated in Section
473+12 5-2.
474+13 The Department of Healthcare and Family Services must
475+14 provide coverage and reimbursement for amino acid-based
476+15 elemental formulas, regardless of delivery method, for the
477+16 diagnosis and treatment of (i) eosinophilic disorders and (ii)
478+17 short bowel syndrome when the prescribing physician has issued
479+18 a written order stating that the amino acid-based elemental
480+19 formula is medically necessary.
481+20 The Illinois Department shall authorize the provision of,
482+21 and shall authorize payment for, screening by low-dose
483+22 mammography for the presence of occult breast cancer for
484+23 individuals 35 years of age or older who are eligible for
485+24 medical assistance under this Article, as follows:
486+25 (A) A baseline mammogram for individuals 35 to 39
487+26 years of age.
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1065-provided for naloxone hydrochloride under the medical
1066-assistance program.
1067-Upon federal approval, the Department shall provide
1068-coverage and reimbursement for all drugs that are approved for
1069-marketing by the federal Food and Drug Administration and that
1070-are recommended by the federal Public Health Service or the
1071-United States Centers for Disease Control and Prevention for
1072-pre-exposure prophylaxis and related pre-exposure prophylaxis
1073-services, including, but not limited to, HIV and sexually
1074-transmitted infection screening, treatment for sexually
1075-transmitted infections, medical monitoring, assorted labs, and
1076-counseling to reduce the likelihood of HIV infection among
1077-individuals who are not infected with HIV but who are at high
1078-risk of HIV infection.
1079-A federally qualified health center, as defined in Section
1080-1905(l)(2)(B) of the federal Social Security Act, shall be
1081-reimbursed by the Department in accordance with the federally
1082-qualified health center's encounter rate for services provided
1083-to medical assistance recipients that are performed by a
1084-dental hygienist, as defined under the Illinois Dental
1085-Practice Act, working under the general supervision of a
1086-dentist and employed by a federally qualified health center.
1087-Within 90 days after October 8, 2021 (the effective date
1088-of Public Act 102-665), the Department shall seek federal
1089-approval of a State Plan amendment to expand coverage for
1090-family planning services that includes presumptive eligibility
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1093-to individuals whose income is at or below 208% of the federal
1094-poverty level. Coverage under this Section shall be effective
1095-beginning no later than December 1, 2022.
1096-Subject to approval by the federal Centers for Medicare
1097-and Medicaid Services of a Title XIX State Plan amendment
1098-electing the Program of All-Inclusive Care for the Elderly
1099-(PACE) as a State Medicaid option, as provided for by Subtitle
1100-I (commencing with Section 4801) of Title IV of the Balanced
1101-Budget Act of 1997 (Public Law 105-33) and Part 460
1102-(commencing with Section 460.2) of Subchapter E of Title 42 of
1103-the Code of Federal Regulations, PACE program services shall
1104-become a covered benefit of the medical assistance program,
1105-subject to criteria established in accordance with all
1106-applicable laws.
1107-Notwithstanding any other provision of this Code,
1108-community-based pediatric palliative care from a trained
1109-interdisciplinary team shall be covered under the medical
1110-assistance program as provided in Section 15 of the Pediatric
1111-Palliative Care Act.
1112-Notwithstanding any other provision of this Code, within
1113-12 months after June 2, 2022 (the effective date of Public Act
1114-102-1037) this amendatory Act of the 102nd General Assembly
1115-and subject to federal approval, acupuncture services
1116-performed by an acupuncturist licensed under the Acupuncture
1117-Practice Act who is acting within the scope of his or her
1118-license shall be covered under the medical assistance program.
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1121-The Department shall apply for any federal waiver or State
1122-Plan amendment, if required, to implement this paragraph. The
1123-Department may adopt any rules, including standards and
1124-criteria, necessary to implement this paragraph.
1125-Notwithstanding any other provision of this Code,
1126-medically necessary reconstructive services that are intended
1127-to restore physical appearance shall be covered under the
1128-medical assistance program for persons who are otherwise
1129-eligible for medical assistance under this Article. As used in
1130-this paragraph, "reconstructive services" means treatments
1131-performed on structures of the body damaged by trauma to
1132-restore physical appearance.
1133-(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
1134-102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1135-35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1136-55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
1137-102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1138-1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
1139-102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1140-1-1-23; revised 2-5-23.)
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498+1 (B) An annual mammogram for individuals 40 years of
499+2 age or older.
500+3 (C) A mammogram at the age and intervals considered
501+4 medically necessary by the individual's health care
502+5 provider for individuals under 40 years of age and having
503+6 a family history of breast cancer, prior personal history
504+7 of breast cancer, positive genetic testing, or other risk
505+8 factors.
506+9 (D) A comprehensive ultrasound screening and MRI of an
507+10 entire breast or breasts if a mammogram demonstrates
508+11 heterogeneous or dense breast tissue or when medically
509+12 necessary as determined by a physician licensed to
510+13 practice medicine in all of its branches.
511+14 (E) A screening MRI when medically necessary, as
512+15 determined by a physician licensed to practice medicine in
513+16 all of its branches.
514+17 (F) A diagnostic mammogram when medically necessary,
515+18 as determined by a physician licensed to practice medicine
516+19 in all its branches, advanced practice registered nurse,
517+20 or physician assistant.
518+21 The Department shall not impose a deductible, coinsurance,
519+22 copayment, or any other cost-sharing requirement on the
520+23 coverage provided under this paragraph; except that this
521+24 sentence does not apply to coverage of diagnostic mammograms
522+25 to the extent such coverage would disqualify a high-deductible
523+26 health plan from eligibility for a health savings account
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534+1 pursuant to Section 223 of the Internal Revenue Code (26
535+2 U.S.C. 223).
536+3 All screenings shall include a physical breast exam,
537+4 instruction on self-examination and information regarding the
538+5 frequency of self-examination and its value as a preventative
539+6 tool.
540+7 For purposes of this Section:
541+8 "Diagnostic mammogram" means a mammogram obtained using
542+9 diagnostic mammography.
543+10 "Diagnostic mammography" means a method of screening that
544+11 is designed to evaluate an abnormality in a breast, including
545+12 an abnormality seen or suspected on a screening mammogram or a
546+13 subjective or objective abnormality otherwise detected in the
547+14 breast.
548+15 "Low-dose mammography" means the x-ray examination of the
549+16 breast using equipment dedicated specifically for mammography,
550+17 including the x-ray tube, filter, compression device, and
551+18 image receptor, with an average radiation exposure delivery of
552+19 less than one rad per breast for 2 views of an average size
553+20 breast. The term also includes digital mammography and
554+21 includes breast tomosynthesis.
555+22 "Breast tomosynthesis" means a radiologic procedure that
556+23 involves the acquisition of projection images over the
557+24 stationary breast to produce cross-sectional digital
558+25 three-dimensional images of the breast.
559+26 If, at any time, the Secretary of the United States
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570+1 Department of Health and Human Services, or its successor
571+2 agency, promulgates rules or regulations to be published in
572+3 the Federal Register or publishes a comment in the Federal
573+4 Register or issues an opinion, guidance, or other action that
574+5 would require the State, pursuant to any provision of the
575+6 Patient Protection and Affordable Care Act (Public Law
576+7 111-148), including, but not limited to, 42 U.S.C.
577+8 18031(d)(3)(B) or any successor provision, to defray the cost
578+9 of any coverage for breast tomosynthesis outlined in this
579+10 paragraph, then the requirement that an insurer cover breast
580+11 tomosynthesis is inoperative other than any such coverage
581+12 authorized under Section 1902 of the Social Security Act, 42
582+13 U.S.C. 1396a, and the State shall not assume any obligation
583+14 for the cost of coverage for breast tomosynthesis set forth in
584+15 this paragraph.
585+16 On and after January 1, 2016, the Department shall ensure
586+17 that all networks of care for adult clients of the Department
587+18 include access to at least one breast imaging Center of
588+19 Imaging Excellence as certified by the American College of
589+20 Radiology.
590+21 On and after January 1, 2012, providers participating in a
591+22 quality improvement program approved by the Department shall
592+23 be reimbursed for screening and diagnostic mammography at the
593+24 same rate as the Medicare program's rates, including the
594+25 increased reimbursement for digital mammography and, after
595+26 January 1, 2023 (the effective date of Public Act 102-1018)
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606+1 this amendatory Act of the 102nd General Assembly, breast
607+2 tomosynthesis.
608+3 The Department shall convene an expert panel including
609+4 representatives of hospitals, free-standing mammography
610+5 facilities, and doctors, including radiologists, to establish
611+6 quality standards for mammography.
612+7 On and after January 1, 2017, providers participating in a
613+8 breast cancer treatment quality improvement program approved
614+9 by the Department shall be reimbursed for breast cancer
615+10 treatment at a rate that is no lower than 95% of the Medicare
616+11 program's rates for the data elements included in the breast
617+12 cancer treatment quality program.
618+13 The Department shall convene an expert panel, including
619+14 representatives of hospitals, free-standing breast cancer
620+15 treatment centers, breast cancer quality organizations, and
621+16 doctors, including breast surgeons, reconstructive breast
622+17 surgeons, oncologists, and primary care providers to establish
623+18 quality standards for breast cancer treatment.
624+19 Subject to federal approval, the Department shall
625+20 establish a rate methodology for mammography at federally
626+21 qualified health centers and other encounter-rate clinics.
627+22 These clinics or centers may also collaborate with other
628+23 hospital-based mammography facilities. By January 1, 2016, the
629+24 Department shall report to the General Assembly on the status
630+25 of the provision set forth in this paragraph.
631+26 The Department shall establish a methodology to remind
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642+1 individuals who are age-appropriate for screening mammography,
643+2 but who have not received a mammogram within the previous 18
644+3 months, of the importance and benefit of screening
645+4 mammography. The Department shall work with experts in breast
646+5 cancer outreach and patient navigation to optimize these
647+6 reminders and shall establish a methodology for evaluating
648+7 their effectiveness and modifying the methodology based on the
649+8 evaluation.
650+9 The Department shall establish a performance goal for
651+10 primary care providers with respect to their female patients
652+11 over age 40 receiving an annual mammogram. This performance
653+12 goal shall be used to provide additional reimbursement in the
654+13 form of a quality performance bonus to primary care providers
655+14 who meet that goal.
656+15 The Department shall devise a means of case-managing or
657+16 patient navigation for beneficiaries diagnosed with breast
658+17 cancer. This program shall initially operate as a pilot
659+18 program in areas of the State with the highest incidence of
660+19 mortality related to breast cancer. At least one pilot program
661+20 site shall be in the metropolitan Chicago area and at least one
662+21 site shall be outside the metropolitan Chicago area. On or
663+22 after July 1, 2016, the pilot program shall be expanded to
664+23 include one site in western Illinois, one site in southern
665+24 Illinois, one site in central Illinois, and 4 sites within
666+25 metropolitan Chicago. An evaluation of the pilot program shall
667+26 be carried out measuring health outcomes and cost of care for
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678+1 those served by the pilot program compared to similarly
679+2 situated patients who are not served by the pilot program.
680+3 The Department shall require all networks of care to
681+4 develop a means either internally or by contract with experts
682+5 in navigation and community outreach to navigate cancer
683+6 patients to comprehensive care in a timely fashion. The
684+7 Department shall require all networks of care to include
685+8 access for patients diagnosed with cancer to at least one
686+9 academic commission on cancer-accredited cancer program as an
687+10 in-network covered benefit.
688+11 The Department shall provide coverage and reimbursement
689+12 for a human papillomavirus (HPV) vaccine that is approved for
690+13 marketing by the federal Food and Drug Administration for all
691+14 persons between the ages of 9 and 45 and persons of the age of
692+15 46 and above who have been diagnosed with cervical dysplasia
693+16 with a high risk of recurrence or progression. The Department
694+17 shall disallow any preauthorization requirements for the
695+18 administration of the human papillomavirus (HPV) vaccine.
696+19 On or after July 1, 2022, individuals who are otherwise
697+20 eligible for medical assistance under this Article shall
698+21 receive coverage for perinatal depression screenings for the
699+22 12-month period beginning on the last day of their pregnancy.
700+23 Medical assistance coverage under this paragraph shall be
701+24 conditioned on the use of a screening instrument approved by
702+25 the Department.
703+26 Any medical or health care provider shall immediately
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714+1 recommend, to any pregnant individual who is being provided
715+2 prenatal services and is suspected of having a substance use
716+3 disorder as defined in the Substance Use Disorder Act,
717+4 referral to a local substance use disorder treatment program
718+5 licensed by the Department of Human Services or to a licensed
719+6 hospital which provides substance abuse treatment services.
720+7 The Department of Healthcare and Family Services shall assure
721+8 coverage for the cost of treatment of the drug abuse or
722+9 addiction for pregnant recipients in accordance with the
723+10 Illinois Medicaid Program in conjunction with the Department
724+11 of Human Services.
725+12 All medical providers providing medical assistance to
726+13 pregnant individuals under this Code shall receive information
727+14 from the Department on the availability of services under any
728+15 program providing case management services for addicted
729+16 individuals, including information on appropriate referrals
730+17 for other social services that may be needed by addicted
731+18 individuals in addition to treatment for addiction.
732+19 The Illinois Department, in cooperation with the
733+20 Departments of Human Services (as successor to the Department
734+21 of Alcoholism and Substance Abuse) and Public Health, through
735+22 a public awareness campaign, may provide information
736+23 concerning treatment for alcoholism and drug abuse and
737+24 addiction, prenatal health care, and other pertinent programs
738+25 directed at reducing the number of drug-affected infants born
739+26 to recipients of medical assistance.
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750+1 Neither the Department of Healthcare and Family Services
751+2 nor the Department of Human Services shall sanction the
752+3 recipient solely on the basis of the recipient's substance
753+4 abuse.
754+5 The Illinois Department shall establish such regulations
755+6 governing the dispensing of health services under this Article
756+7 as it shall deem appropriate. The Department should seek the
757+8 advice of formal professional advisory committees appointed by
758+9 the Director of the Illinois Department for the purpose of
759+10 providing regular advice on policy and administrative matters,
760+11 information dissemination and educational activities for
761+12 medical and health care providers, and consistency in
762+13 procedures to the Illinois Department.
763+14 The Illinois Department may develop and contract with
764+15 Partnerships of medical providers to arrange medical services
765+16 for persons eligible under Section 5-2 of this Code.
766+17 Implementation of this Section may be by demonstration
767+18 projects in certain geographic areas. The Partnership shall be
768+19 represented by a sponsor organization. The Department, by
769+20 rule, shall develop qualifications for sponsors of
770+21 Partnerships. Nothing in this Section shall be construed to
771+22 require that the sponsor organization be a medical
772+23 organization.
773+24 The sponsor must negotiate formal written contracts with
774+25 medical providers for physician services, inpatient and
775+26 outpatient hospital care, home health services, treatment for
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786+1 alcoholism and substance abuse, and other services determined
787+2 necessary by the Illinois Department by rule for delivery by
788+3 Partnerships. Physician services must include prenatal and
789+4 obstetrical care. The Illinois Department shall reimburse
790+5 medical services delivered by Partnership providers to clients
791+6 in target areas according to provisions of this Article and
792+7 the Illinois Health Finance Reform Act, except that:
793+8 (1) Physicians participating in a Partnership and
794+9 providing certain services, which shall be determined by
795+10 the Illinois Department, to persons in areas covered by
796+11 the Partnership may receive an additional surcharge for
797+12 such services.
798+13 (2) The Department may elect to consider and negotiate
799+14 financial incentives to encourage the development of
800+15 Partnerships and the efficient delivery of medical care.
801+16 (3) Persons receiving medical services through
802+17 Partnerships may receive medical and case management
803+18 services above the level usually offered through the
804+19 medical assistance program.
805+20 Medical providers shall be required to meet certain
806+21 qualifications to participate in Partnerships to ensure the
807+22 delivery of high quality medical services. These
808+23 qualifications shall be determined by rule of the Illinois
809+24 Department and may be higher than qualifications for
810+25 participation in the medical assistance program. Partnership
811+26 sponsors may prescribe reasonable additional qualifications
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822+1 for participation by medical providers, only with the prior
823+2 written approval of the Illinois Department.
824+3 Nothing in this Section shall limit the free choice of
825+4 practitioners, hospitals, and other providers of medical
826+5 services by clients. In order to ensure patient freedom of
827+6 choice, the Illinois Department shall immediately promulgate
828+7 all rules and take all other necessary actions so that
829+8 provided services may be accessed from therapeutically
830+9 certified optometrists to the full extent of the Illinois
831+10 Optometric Practice Act of 1987 without discriminating between
832+11 service providers.
833+12 The Department shall apply for a waiver from the United
834+13 States Health Care Financing Administration to allow for the
835+14 implementation of Partnerships under this Section.
836+15 The Illinois Department shall require health care
837+16 providers to maintain records that document the medical care
838+17 and services provided to recipients of Medical Assistance
839+18 under this Article. Such records must be retained for a period
840+19 of not less than 6 years from the date of service or as
841+20 provided by applicable State law, whichever period is longer,
842+21 except that if an audit is initiated within the required
843+22 retention period then the records must be retained until the
844+23 audit is completed and every exception is resolved. The
845+24 Illinois Department shall require health care providers to
846+25 make available, when authorized by the patient, in writing,
847+26 the medical records in a timely fashion to other health care
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858+1 providers who are treating or serving persons eligible for
859+2 Medical Assistance under this Article. All dispensers of
860+3 medical services shall be required to maintain and retain
861+4 business and professional records sufficient to fully and
862+5 accurately document the nature, scope, details and receipt of
863+6 the health care provided to persons eligible for medical
864+7 assistance under this Code, in accordance with regulations
865+8 promulgated by the Illinois Department. The rules and
866+9 regulations shall require that proof of the receipt of
867+10 prescription drugs, dentures, prosthetic devices and
868+11 eyeglasses by eligible persons under this Section accompany
869+12 each claim for reimbursement submitted by the dispenser of
870+13 such medical services. No such claims for reimbursement shall
871+14 be approved for payment by the Illinois Department without
872+15 such proof of receipt, unless the Illinois Department shall
873+16 have put into effect and shall be operating a system of
874+17 post-payment audit and review which shall, on a sampling
875+18 basis, be deemed adequate by the Illinois Department to assure
876+19 that such drugs, dentures, prosthetic devices and eyeglasses
877+20 for which payment is being made are actually being received by
878+21 eligible recipients. Within 90 days after September 16, 1984
879+22 (the effective date of Public Act 83-1439), the Illinois
880+23 Department shall establish a current list of acquisition costs
881+24 for all prosthetic devices and any other items recognized as
882+25 medical equipment and supplies reimbursable under this Article
883+26 and shall update such list on a quarterly basis, except that
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894+1 the acquisition costs of all prescription drugs shall be
895+2 updated no less frequently than every 30 days as required by
896+3 Section 5-5.12.
897+4 Notwithstanding any other law to the contrary, the
898+5 Illinois Department shall, within 365 days after July 22, 2013
899+6 (the effective date of Public Act 98-104), establish
900+7 procedures to permit skilled care facilities licensed under
901+8 the Nursing Home Care Act to submit monthly billing claims for
902+9 reimbursement purposes. Following development of these
903+10 procedures, the Department shall, by July 1, 2016, test the
904+11 viability of the new system and implement any necessary
905+12 operational or structural changes to its information
906+13 technology platforms in order to allow for the direct
907+14 acceptance and payment of nursing home claims.
908+15 Notwithstanding any other law to the contrary, the
909+16 Illinois Department shall, within 365 days after August 15,
910+17 2014 (the effective date of Public Act 98-963), establish
911+18 procedures to permit ID/DD facilities licensed under the ID/DD
912+19 Community Care Act and MC/DD facilities licensed under the
913+20 MC/DD Act to submit monthly billing claims for reimbursement
914+21 purposes. Following development of these procedures, the
915+22 Department shall have an additional 365 days to test the
916+23 viability of the new system and to ensure that any necessary
917+24 operational or structural changes to its information
918+25 technology platforms are implemented.
919+26 The Illinois Department shall require all dispensers of
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930+1 medical services, other than an individual practitioner or
931+2 group of practitioners, desiring to participate in the Medical
932+3 Assistance program established under this Article to disclose
933+4 all financial, beneficial, ownership, equity, surety or other
934+5 interests in any and all firms, corporations, partnerships,
935+6 associations, business enterprises, joint ventures, agencies,
936+7 institutions or other legal entities providing any form of
937+8 health care services in this State under this Article.
938+9 The Illinois Department may require that all dispensers of
939+10 medical services desiring to participate in the medical
940+11 assistance program established under this Article disclose,
941+12 under such terms and conditions as the Illinois Department may
942+13 by rule establish, all inquiries from clients and attorneys
943+14 regarding medical bills paid by the Illinois Department, which
944+15 inquiries could indicate potential existence of claims or
945+16 liens for the Illinois Department.
946+17 Enrollment of a vendor shall be subject to a provisional
947+18 period and shall be conditional for one year. During the
948+19 period of conditional enrollment, the Department may terminate
949+20 the vendor's eligibility to participate in, or may disenroll
950+21 the vendor from, the medical assistance program without cause.
951+22 Unless otherwise specified, such termination of eligibility or
952+23 disenrollment is not subject to the Department's hearing
953+24 process. However, a disenrolled vendor may reapply without
954+25 penalty.
955+26 The Department has the discretion to limit the conditional
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966+1 enrollment period for vendors based upon the category of risk
967+2 of the vendor.
968+3 Prior to enrollment and during the conditional enrollment
969+4 period in the medical assistance program, all vendors shall be
970+5 subject to enhanced oversight, screening, and review based on
971+6 the risk of fraud, waste, and abuse that is posed by the
972+7 category of risk of the vendor. The Illinois Department shall
973+8 establish the procedures for oversight, screening, and review,
974+9 which may include, but need not be limited to: criminal and
975+10 financial background checks; fingerprinting; license,
976+11 certification, and authorization verifications; unscheduled or
977+12 unannounced site visits; database checks; prepayment audit
978+13 reviews; audits; payment caps; payment suspensions; and other
979+14 screening as required by federal or State law.
980+15 The Department shall define or specify the following: (i)
981+16 by provider notice, the "category of risk of the vendor" for
982+17 each type of vendor, which shall take into account the level of
983+18 screening applicable to a particular category of vendor under
984+19 federal law and regulations; (ii) by rule or provider notice,
985+20 the maximum length of the conditional enrollment period for
986+21 each category of risk of the vendor; and (iii) by rule, the
987+22 hearing rights, if any, afforded to a vendor in each category
988+23 of risk of the vendor that is terminated or disenrolled during
989+24 the conditional enrollment period.
990+25 To be eligible for payment consideration, a vendor's
991+26 payment claim or bill, either as an initial claim or as a
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1002+1 resubmitted claim following prior rejection, must be received
1003+2 by the Illinois Department, or its fiscal intermediary, no
1004+3 later than 180 days after the latest date on the claim on which
1005+4 medical goods or services were provided, with the following
1006+5 exceptions:
1007+6 (1) In the case of a provider whose enrollment is in
1008+7 process by the Illinois Department, the 180-day period
1009+8 shall not begin until the date on the written notice from
1010+9 the Illinois Department that the provider enrollment is
1011+10 complete.
1012+11 (2) In the case of errors attributable to the Illinois
1013+12 Department or any of its claims processing intermediaries
1014+13 which result in an inability to receive, process, or
1015+14 adjudicate a claim, the 180-day period shall not begin
1016+15 until the provider has been notified of the error.
1017+16 (3) In the case of a provider for whom the Illinois
1018+17 Department initiates the monthly billing process.
1019+18 (4) In the case of a provider operated by a unit of
1020+19 local government with a population exceeding 3,000,000
1021+20 when local government funds finance federal participation
1022+21 for claims payments.
1023+22 For claims for services rendered during a period for which
1024+23 a recipient received retroactive eligibility, claims must be
1025+24 filed within 180 days after the Department determines the
1026+25 applicant is eligible. For claims for which the Illinois
1027+26 Department is not the primary payer, claims must be submitted
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1038+1 to the Illinois Department within 180 days after the final
1039+2 adjudication by the primary payer.
1040+3 In the case of long term care facilities, within 120
1041+4 calendar days of receipt by the facility of required
1042+5 prescreening information, new admissions with associated
1043+6 admission documents shall be submitted through the Medical
1044+7 Electronic Data Interchange (MEDI) or the Recipient
1045+8 Eligibility Verification (REV) System or shall be submitted
1046+9 directly to the Department of Human Services using required
1047+10 admission forms. Effective September 1, 2014, admission
1048+11 documents, including all prescreening information, must be
1049+12 submitted through MEDI or REV. Confirmation numbers assigned
1050+13 to an accepted transaction shall be retained by a facility to
1051+14 verify timely submittal. Once an admission transaction has
1052+15 been completed, all resubmitted claims following prior
1053+16 rejection are subject to receipt no later than 180 days after
1054+17 the admission transaction has been completed.
1055+18 Claims that are not submitted and received in compliance
1056+19 with the foregoing requirements shall not be eligible for
1057+20 payment under the medical assistance program, and the State
1058+21 shall have no liability for payment of those claims.
1059+22 To the extent consistent with applicable information and
1060+23 privacy, security, and disclosure laws, State and federal
1061+24 agencies and departments shall provide the Illinois Department
1062+25 access to confidential and other information and data
1063+26 necessary to perform eligibility and payment verifications and
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1074+1 other Illinois Department functions. This includes, but is not
1075+2 limited to: information pertaining to licensure;
1076+3 certification; earnings; immigration status; citizenship; wage
1077+4 reporting; unearned and earned income; pension income;
1078+5 employment; supplemental security income; social security
1079+6 numbers; National Provider Identifier (NPI) numbers; the
1080+7 National Practitioner Data Bank (NPDB); program and agency
1081+8 exclusions; taxpayer identification numbers; tax delinquency;
1082+9 corporate information; and death records.
1083+10 The Illinois Department shall enter into agreements with
1084+11 State agencies and departments, and is authorized to enter
1085+12 into agreements with federal agencies and departments, under
1086+13 which such agencies and departments shall share data necessary
1087+14 for medical assistance program integrity functions and
1088+15 oversight. The Illinois Department shall develop, in
1089+16 cooperation with other State departments and agencies, and in
1090+17 compliance with applicable federal laws and regulations,
1091+18 appropriate and effective methods to share such data. At a
1092+19 minimum, and to the extent necessary to provide data sharing,
1093+20 the Illinois Department shall enter into agreements with State
1094+21 agencies and departments, and is authorized to enter into
1095+22 agreements with federal agencies and departments, including,
1096+23 but not limited to: the Secretary of State; the Department of
1097+24 Revenue; the Department of Public Health; the Department of
1098+25 Human Services; and the Department of Financial and
1099+26 Professional Regulation.
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1110+1 Beginning in fiscal year 2013, the Illinois Department
1111+2 shall set forth a request for information to identify the
1112+3 benefits of a pre-payment, post-adjudication, and post-edit
1113+4 claims system with the goals of streamlining claims processing
1114+5 and provider reimbursement, reducing the number of pending or
1115+6 rejected claims, and helping to ensure a more transparent
1116+7 adjudication process through the utilization of: (i) provider
1117+8 data verification and provider screening technology; and (ii)
1118+9 clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
1119+10 or post-adjudicated predictive modeling with an integrated
1120+11 case management system with link analysis. Such a request for
1121+12 information shall not be considered as a request for proposal
1122+13 or as an obligation on the part of the Illinois Department to
1123+14 take any action or acquire any products or services.
1124+15 The Illinois Department shall establish policies,
1125+16 procedures, standards and criteria by rule for the
1126+17 acquisition, repair and replacement of orthotic and prosthetic
1127+18 devices and durable medical equipment. Such rules shall
1128+19 provide, but not be limited to, the following services: (1)
1129+20 immediate repair or replacement of such devices by recipients;
1130+21 and (2) rental, lease, purchase or lease-purchase of durable
1131+22 medical equipment in a cost-effective manner, taking into
1132+23 consideration the recipient's medical prognosis, the extent of
1133+24 the recipient's needs, and the requirements and costs for
1134+25 maintaining such equipment. Subject to prior approval, such
1135+26 rules shall enable a recipient to temporarily acquire and use
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1146+1 alternative or substitute devices or equipment pending repairs
1147+2 or replacements of any device or equipment previously
1148+3 authorized for such recipient by the Department.
1149+4 Notwithstanding any provision of Section 5-5f to the contrary,
1150+5 the Department may, by rule, exempt certain replacement
1151+6 wheelchair parts from prior approval and, for wheelchairs,
1152+7 wheelchair parts, wheelchair accessories, and related seating
1153+8 and positioning items, determine the wholesale price by
1154+9 methods other than actual acquisition costs.
1155+10 The Department shall require, by rule, all providers of
1156+11 durable medical equipment to be accredited by an accreditation
1157+12 organization approved by the federal Centers for Medicare and
1158+13 Medicaid Services and recognized by the Department in order to
1159+14 bill the Department for providing durable medical equipment to
1160+15 recipients. No later than 15 months after the effective date
1161+16 of the rule adopted pursuant to this paragraph, all providers
1162+17 must meet the accreditation requirement.
1163+18 In order to promote environmental responsibility, meet the
1164+19 needs of recipients and enrollees, and achieve significant
1165+20 cost savings, the Department, or a managed care organization
1166+21 under contract with the Department, may provide recipients or
1167+22 managed care enrollees who have a prescription or Certificate
1168+23 of Medical Necessity access to refurbished durable medical
1169+24 equipment under this Section (excluding prosthetic and
1170+25 orthotic devices as defined in the Orthotics, Prosthetics, and
1171+26 Pedorthics Practice Act and complex rehabilitation technology
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1182+1 products and associated services) through the State's
1183+2 assistive technology program's reutilization program, using
1184+3 staff with the Assistive Technology Professional (ATP)
1185+4 Certification if the refurbished durable medical equipment:
1186+5 (i) is available; (ii) is less expensive, including shipping
1187+6 costs, than new durable medical equipment of the same type;
1188+7 (iii) is able to withstand at least 3 years of use; (iv) is
1189+8 cleaned, disinfected, sterilized, and safe in accordance with
1190+9 federal Food and Drug Administration regulations and guidance
1191+10 governing the reprocessing of medical devices in health care
1192+11 settings; and (v) equally meets the needs of the recipient or
1193+12 enrollee. The reutilization program shall confirm that the
1194+13 recipient or enrollee is not already in receipt of the same or
1195+14 similar equipment from another service provider, and that the
1196+15 refurbished durable medical equipment equally meets the needs
1197+16 of the recipient or enrollee. Nothing in this paragraph shall
1198+17 be construed to limit recipient or enrollee choice to obtain
1199+18 new durable medical equipment or place any additional prior
1200+19 authorization conditions on enrollees of managed care
1201+20 organizations.
1202+21 The Department shall execute, relative to the nursing home
1203+22 prescreening project, written inter-agency agreements with the
1204+23 Department of Human Services and the Department on Aging, to
1205+24 effect the following: (i) intake procedures and common
1206+25 eligibility criteria for those persons who are receiving
1207+26 non-institutional services; and (ii) the establishment and
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1218+1 development of non-institutional services in areas of the
1219+2 State where they are not currently available or are
1220+3 undeveloped; and (iii) notwithstanding any other provision of
1221+4 law, subject to federal approval, on and after July 1, 2012, an
1222+5 increase in the determination of need (DON) scores from 29 to
1223+6 37 for applicants for institutional and home and
1224+7 community-based long term care; if and only if federal
1225+8 approval is not granted, the Department may, in conjunction
1226+9 with other affected agencies, implement utilization controls
1227+10 or changes in benefit packages to effectuate a similar savings
1228+11 amount for this population; and (iv) no later than July 1,
1229+12 2013, minimum level of care eligibility criteria for
1230+13 institutional and home and community-based long term care; and
1231+14 (v) no later than October 1, 2013, establish procedures to
1232+15 permit long term care providers access to eligibility scores
1233+16 for individuals with an admission date who are seeking or
1234+17 receiving services from the long term care provider. In order
1235+18 to select the minimum level of care eligibility criteria, the
1236+19 Governor shall establish a workgroup that includes affected
1237+20 agency representatives and stakeholders representing the
1238+21 institutional and home and community-based long term care
1239+22 interests. This Section shall not restrict the Department from
1240+23 implementing lower level of care eligibility criteria for
1241+24 community-based services in circumstances where federal
1242+25 approval has been granted.
1243+26 The Illinois Department shall develop and operate, in
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1254+1 cooperation with other State Departments and agencies and in
1255+2 compliance with applicable federal laws and regulations,
1256+3 appropriate and effective systems of health care evaluation
1257+4 and programs for monitoring of utilization of health care
1258+5 services and facilities, as it affects persons eligible for
1259+6 medical assistance under this Code.
1260+7 The Illinois Department shall report annually to the
1261+8 General Assembly, no later than the second Friday in April of
1262+9 1979 and each year thereafter, in regard to:
1263+10 (a) actual statistics and trends in utilization of
1264+11 medical services by public aid recipients;
1265+12 (b) actual statistics and trends in the provision of
1266+13 the various medical services by medical vendors;
1267+14 (c) current rate structures and proposed changes in
1268+15 those rate structures for the various medical vendors; and
1269+16 (d) efforts at utilization review and control by the
1270+17 Illinois Department.
1271+18 The period covered by each report shall be the 3 years
1272+19 ending on the June 30 prior to the report. The report shall
1273+20 include suggested legislation for consideration by the General
1274+21 Assembly. The requirement for reporting to the General
1275+22 Assembly shall be satisfied by filing copies of the report as
1276+23 required by Section 3.1 of the General Assembly Organization
1277+24 Act, and filing such additional copies with the State
1278+25 Government Report Distribution Center for the General Assembly
1279+26 as is required under paragraph (t) of Section 7 of the State
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1290+1 Library Act.
1291+2 Rulemaking authority to implement Public Act 95-1045, if
1292+3 any, is conditioned on the rules being adopted in accordance
1293+4 with all provisions of the Illinois Administrative Procedure
1294+5 Act and all rules and procedures of the Joint Committee on
1295+6 Administrative Rules; any purported rule not so adopted, for
1296+7 whatever reason, is unauthorized.
1297+8 On and after July 1, 2012, the Department shall reduce any
1298+9 rate of reimbursement for services or other payments or alter
1299+10 any methodologies authorized by this Code to reduce any rate
1300+11 of reimbursement for services or other payments in accordance
1301+12 with Section 5-5e.
1302+13 Because kidney transplantation can be an appropriate,
1303+14 cost-effective alternative to renal dialysis when medically
1304+15 necessary and notwithstanding the provisions of Section 1-11
1305+16 of this Code, beginning October 1, 2014, the Department shall
1306+17 cover kidney transplantation for noncitizens with end-stage
1307+18 renal disease who are not eligible for comprehensive medical
1308+19 benefits, who meet the residency requirements of Section 5-3
1309+20 of this Code, and who would otherwise meet the financial
1310+21 requirements of the appropriate class of eligible persons
1311+22 under Section 5-2 of this Code. To qualify for coverage of
1312+23 kidney transplantation, such person must be receiving
1313+24 emergency renal dialysis services covered by the Department.
1314+25 Providers under this Section shall be prior approved and
1315+26 certified by the Department to perform kidney transplantation
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1326+1 and the services under this Section shall be limited to
1327+2 services associated with kidney transplantation.
1328+3 Notwithstanding any other provision of this Code to the
1329+4 contrary, on or after July 1, 2015, all FDA approved forms of
1330+5 medication assisted treatment prescribed for the treatment of
1331+6 alcohol dependence or treatment of opioid dependence shall be
1332+7 covered under both fee for service and managed care medical
1333+8 assistance programs for persons who are otherwise eligible for
1334+9 medical assistance under this Article and shall not be subject
1335+10 to any (1) utilization control, other than those established
1336+11 under the American Society of Addiction Medicine patient
1337+12 placement criteria, (2) prior authorization mandate, or (3)
1338+13 lifetime restriction limit mandate.
1339+14 On or after July 1, 2015, opioid antagonists prescribed
1340+15 for the treatment of an opioid overdose, including the
1341+16 medication product, administration devices, and any pharmacy
1342+17 fees or hospital fees related to the dispensing, distribution,
1343+18 and administration of the opioid antagonist, shall be covered
1344+19 under the medical assistance program for persons who are
1345+20 otherwise eligible for medical assistance under this Article.
1346+21 As used in this Section, "opioid antagonist" means a drug that
1347+22 binds to opioid receptors and blocks or inhibits the effect of
1348+23 opioids acting on those receptors, including, but not limited
1349+24 to, naloxone hydrochloride or any other similarly acting drug
1350+25 approved by the U.S. Food and Drug Administration. The
1351+26 Department shall not impose a copayment on the coverage
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1362+1 provided for naloxone hydrochloride under the medical
1363+2 assistance program.
1364+3 Upon federal approval, the Department shall provide
1365+4 coverage and reimbursement for all drugs that are approved for
1366+5 marketing by the federal Food and Drug Administration and that
1367+6 are recommended by the federal Public Health Service or the
1368+7 United States Centers for Disease Control and Prevention for
1369+8 pre-exposure prophylaxis and related pre-exposure prophylaxis
1370+9 services, including, but not limited to, HIV and sexually
1371+10 transmitted infection screening, treatment for sexually
1372+11 transmitted infections, medical monitoring, assorted labs, and
1373+12 counseling to reduce the likelihood of HIV infection among
1374+13 individuals who are not infected with HIV but who are at high
1375+14 risk of HIV infection.
1376+15 A federally qualified health center, as defined in Section
1377+16 1905(l)(2)(B) of the federal Social Security Act, shall be
1378+17 reimbursed by the Department in accordance with the federally
1379+18 qualified health center's encounter rate for services provided
1380+19 to medical assistance recipients that are performed by a
1381+20 dental hygienist, as defined under the Illinois Dental
1382+21 Practice Act, working under the general supervision of a
1383+22 dentist and employed by a federally qualified health center.
1384+23 Within 90 days after October 8, 2021 (the effective date
1385+24 of Public Act 102-665), the Department shall seek federal
1386+25 approval of a State Plan amendment to expand coverage for
1387+26 family planning services that includes presumptive eligibility
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1398+1 to individuals whose income is at or below 208% of the federal
1399+2 poverty level. Coverage under this Section shall be effective
1400+3 beginning no later than December 1, 2022.
1401+4 Subject to approval by the federal Centers for Medicare
1402+5 and Medicaid Services of a Title XIX State Plan amendment
1403+6 electing the Program of All-Inclusive Care for the Elderly
1404+7 (PACE) as a State Medicaid option, as provided for by Subtitle
1405+8 I (commencing with Section 4801) of Title IV of the Balanced
1406+9 Budget Act of 1997 (Public Law 105-33) and Part 460
1407+10 (commencing with Section 460.2) of Subchapter E of Title 42 of
1408+11 the Code of Federal Regulations, PACE program services shall
1409+12 become a covered benefit of the medical assistance program,
1410+13 subject to criteria established in accordance with all
1411+14 applicable laws.
1412+15 Notwithstanding any other provision of this Code,
1413+16 community-based pediatric palliative care from a trained
1414+17 interdisciplinary team shall be covered under the medical
1415+18 assistance program as provided in Section 15 of the Pediatric
1416+19 Palliative Care Act.
1417+20 Notwithstanding any other provision of this Code, within
1418+21 12 months after June 2, 2022 (the effective date of Public Act
1419+22 102-1037) this amendatory Act of the 102nd General Assembly
1420+23 and subject to federal approval, acupuncture services
1421+24 performed by an acupuncturist licensed under the Acupuncture
1422+25 Practice Act who is acting within the scope of his or her
1423+26 license shall be covered under the medical assistance program.
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1434+1 The Department shall apply for any federal waiver or State
1435+2 Plan amendment, if required, to implement this paragraph. The
1436+3 Department may adopt any rules, including standards and
1437+4 criteria, necessary to implement this paragraph.
1438+5 Notwithstanding any other provision of this Code,
1439+6 medically necessary reconstructive services that are intended
1440+7 to restore physical appearance shall be covered under the
1441+8 medical assistance program for persons who are otherwise
1442+9 eligible for medical assistance under this Article. As used in
1443+10 this paragraph, "reconstructive services" means treatments
1444+11 performed on structures of the body damaged by trauma to
1445+12 restore physical appearance.
1446+13 (Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
1447+14 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1448+15 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1449+16 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
1450+17 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1451+18 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
1452+19 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1453+20 1-1-23; revised 2-5-23.)
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