Illinois 2023 2023-2024 Regular Session

Illinois House Bill HB5203 Introduced / Bill

Filed 02/08/2024

103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5203 Introduced , by Rep. Brad Halbrook SYNOPSIS AS INTRODUCED: New Act5 ILCS 375/6 from Ch. 127, par. 5265 ILCS 375/6.1 from Ch. 127, par. 526.1305 ILCS 5/5-5305 ILCS 5/5-8 from Ch. 23, par. 5-8305 ILCS 5/5-9 from Ch. 23, par. 5-9305 ILCS 5/6-1 from Ch. 23, par. 6-1410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100 Creates the No Taxpayer Funding for Abortion Act. Provides that neither the State nor any of its subdivisions may authorize the use of, appropriate, or expend funds to pay for an abortion or to cover any part of the costs of a health plan that includes coverage of abortion or to provide or refer for an abortion, unless a woman who suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death if an abortion is not performed. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code. Excludes from the programs of health benefits and services authorized under those Acts coverage for elective abortions as provided in the No Taxpayer Funding for Abortion Act. Prohibits a physician who has been found guilty of performing an abortion procedure in a willful and wanton manner upon a woman who was not pregnant when the abortion procedure was performed from participating in the State's Medical Assistance Program. Provides that the Department of Healthcare and Family Services shall require a written statement, including the required opinion of a physician, to accompany a claim for reimbursement for abortions or induced miscarriages or premature births. Makes other changes. Amends the Problem Pregnancy Health Services and Care Act. Permits the Department of Human Services to make grants to nonprofit agencies and organizations that do not use those grants to refer or counsel for, or perform, abortions. Contains provisions regarding applicability and preempts home rule. Effective June 1, 2024. LRB103 38434 KTG 68570 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5203 Introduced , by Rep. Brad Halbrook SYNOPSIS AS INTRODUCED: New Act5 ILCS 375/6 from Ch. 127, par. 5265 ILCS 375/6.1 from Ch. 127, par. 526.1305 ILCS 5/5-5305 ILCS 5/5-8 from Ch. 23, par. 5-8305 ILCS 5/5-9 from Ch. 23, par. 5-9305 ILCS 5/6-1 from Ch. 23, par. 6-1410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100 New Act 5 ILCS 375/6 from Ch. 127, par. 526 5 ILCS 375/6.1 from Ch. 127, par. 526.1 305 ILCS 5/5-5 305 ILCS 5/5-8 from Ch. 23, par. 5-8 305 ILCS 5/5-9 from Ch. 23, par. 5-9 305 ILCS 5/6-1 from Ch. 23, par. 6-1 410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100 Creates the No Taxpayer Funding for Abortion Act. Provides that neither the State nor any of its subdivisions may authorize the use of, appropriate, or expend funds to pay for an abortion or to cover any part of the costs of a health plan that includes coverage of abortion or to provide or refer for an abortion, unless a woman who suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death if an abortion is not performed. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code. Excludes from the programs of health benefits and services authorized under those Acts coverage for elective abortions as provided in the No Taxpayer Funding for Abortion Act. Prohibits a physician who has been found guilty of performing an abortion procedure in a willful and wanton manner upon a woman who was not pregnant when the abortion procedure was performed from participating in the State's Medical Assistance Program. Provides that the Department of Healthcare and Family Services shall require a written statement, including the required opinion of a physician, to accompany a claim for reimbursement for abortions or induced miscarriages or premature births. Makes other changes. Amends the Problem Pregnancy Health Services and Care Act. Permits the Department of Human Services to make grants to nonprofit agencies and organizations that do not use those grants to refer or counsel for, or perform, abortions. Contains provisions regarding applicability and preempts home rule. Effective June 1, 2024. LRB103 38434 KTG 68570 b LRB103 38434 KTG 68570 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5203 Introduced , by Rep. Brad Halbrook SYNOPSIS AS INTRODUCED:
New Act5 ILCS 375/6 from Ch. 127, par. 5265 ILCS 375/6.1 from Ch. 127, par. 526.1305 ILCS 5/5-5305 ILCS 5/5-8 from Ch. 23, par. 5-8305 ILCS 5/5-9 from Ch. 23, par. 5-9305 ILCS 5/6-1 from Ch. 23, par. 6-1410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100 New Act 5 ILCS 375/6 from Ch. 127, par. 526 5 ILCS 375/6.1 from Ch. 127, par. 526.1 305 ILCS 5/5-5 305 ILCS 5/5-8 from Ch. 23, par. 5-8 305 ILCS 5/5-9 from Ch. 23, par. 5-9 305 ILCS 5/6-1 from Ch. 23, par. 6-1 410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100
New Act
5 ILCS 375/6 from Ch. 127, par. 526
5 ILCS 375/6.1 from Ch. 127, par. 526.1
305 ILCS 5/5-5
305 ILCS 5/5-8 from Ch. 23, par. 5-8
305 ILCS 5/5-9 from Ch. 23, par. 5-9
305 ILCS 5/6-1 from Ch. 23, par. 6-1
410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100
Creates the No Taxpayer Funding for Abortion Act. Provides that neither the State nor any of its subdivisions may authorize the use of, appropriate, or expend funds to pay for an abortion or to cover any part of the costs of a health plan that includes coverage of abortion or to provide or refer for an abortion, unless a woman who suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death if an abortion is not performed. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code. Excludes from the programs of health benefits and services authorized under those Acts coverage for elective abortions as provided in the No Taxpayer Funding for Abortion Act. Prohibits a physician who has been found guilty of performing an abortion procedure in a willful and wanton manner upon a woman who was not pregnant when the abortion procedure was performed from participating in the State's Medical Assistance Program. Provides that the Department of Healthcare and Family Services shall require a written statement, including the required opinion of a physician, to accompany a claim for reimbursement for abortions or induced miscarriages or premature births. Makes other changes. Amends the Problem Pregnancy Health Services and Care Act. Permits the Department of Human Services to make grants to nonprofit agencies and organizations that do not use those grants to refer or counsel for, or perform, abortions. Contains provisions regarding applicability and preempts home rule. Effective June 1, 2024.
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A BILL FOR
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1 AN ACT concerning abortion.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the No
5 Taxpayer Funding for Abortion Act.
6 Section 5. Public policy. It is the public policy of this
7 State that the General Assembly of the State of Illinois does
8 solemnly declare and find in reaffirmation of the longstanding
9 policy of this State that the unborn child is a human being
10 from the time of conception and has a right to life and, to the
11 extent consistent with the United States Constitution,
12 Illinois law should be interpreted to recognize that right to
13 life and to protect unborn life.
14 The General Assembly further declares and finds that,
15 while the people of Illinois hold a variety of positions on the
16 issue of abortion, they generally oppose the use of tax
17 dollars to pay for elective abortions and support the federal
18 Hyde Amendment, named after the late Henry J. Hyde, whose
19 memory is revered and service celebrated as a Congressman from
20 the great State of Illinois. This Act honors the strong
21 beliefs of the people of Illinois by prohibiting the taxpayer
22 funding of abortion in this State.

New Act
5 ILCS 375/6 from Ch. 127, par. 526
5 ILCS 375/6.1 from Ch. 127, par. 526.1
305 ILCS 5/5-5
305 ILCS 5/5-8 from Ch. 23, par. 5-8
305 ILCS 5/5-9 from Ch. 23, par. 5-9
305 ILCS 5/6-1 from Ch. 23, par. 6-1
410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100

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1 Section 10. Use of funds to pay for abortions prohibited;
2 exceptions. Notwithstanding any other provision of law,
3 neither the State nor any of its subdivisions may authorize
4 the use of, appropriate, or expend any funds to pay for any
5 abortion or to cover any part of the costs of any health plan
6 that includes coverage of abortion or to provide or refer for
7 any abortion, except in the case where a woman suffers from a
8 physical disorder, physical injury, or physical illness that
9 would, as certified by a physician, place the woman in danger
10 of death unless an abortion is performed, including a
11 life-endangering physical condition caused by or arising from
12 the pregnancy itself, or in such other circumstances as
13 required by federal law.
14 Section 900. The State Employees Group Insurance Act of
15 1971 is amended by changing Sections 6 and 6.1 as follows:
16 (5 ILCS 375/6) (from Ch. 127, par. 526)
17 Sec. 6. Program of health benefits.
18 (a) The program of health benefits shall provide for
19 protection against the financial costs of health care expenses
20 incurred in and out of hospital including basic
21 hospital-surgical-medical coverages. The program may include,
22 but shall not be limited to, such supplemental coverages as
23 out-patient diagnostic X-ray and laboratory expenses,
24 prescription drugs, dental services, hearing evaluations,

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1 hearing aids, the dispensing and fitting of hearing aids, and
2 similar group benefits as are now or may become available,
3 except as provided in the No Taxpayer Funding for Abortion
4 Act. The program may also include coverage for those who rely
5 on treatment by prayer or spiritual means alone for healing in
6 accordance with the tenets and practice of a recognized
7 religious denomination.
8 The program of health benefits shall be designed by the
9 Director (1) to provide a reasonable relationship between the
10 benefits to be included and the expected distribution of
11 expenses of each such type to be incurred by the covered
12 members and dependents, (2) to specify, as covered benefits
13 and as optional benefits, the medical services of
14 practitioners in all categories licensed under the Medical
15 Practice Act of 1987, (3) to include reasonable controls,
16 which may include deductible and co-insurance provisions,
17 applicable to some or all of the benefits, or a coordination of
18 benefits provision, to prevent or minimize unnecessary
19 utilization of the various hospital, surgical and medical
20 expenses to be provided and to provide reasonable assurance of
21 stability of the program, and (4) to provide benefits to the
22 extent possible to members throughout the State, wherever
23 located, on an equitable basis. Notwithstanding any other
24 provision of this Section or Act, for all members or
25 dependents who are eligible for benefits under Social Security
26 or the Railroad Retirement system or who had sufficient

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1 Medicare-covered government employment, the Department shall
2 reduce benefits which would otherwise be paid by Medicare, by
3 the amount of benefits for which the member or dependents are
4 eligible under Medicare, except that such reduction in
5 benefits shall apply only to those members or dependents who
6 (1) first become eligible for such medicare coverage on or
7 after the effective date of this amendatory Act of 1992; or (2)
8 are Medicare-eligible members or dependents of a local
9 government unit which began participation in the program on or
10 after July 1, 1992; or (3) remain eligible for but no longer
11 receive Medicare coverage which they had been receiving on or
12 after the effective date of this amendatory Act of 1992.
13 Notwithstanding any other provisions of this Act, where a
14 covered member or dependents are eligible for benefits under
15 the federal Medicare health insurance program (Title XVIII of
16 the Social Security Act as added by Public Law 89-97, 89th
17 Congress), benefits paid under the State of Illinois program
18 or plan will be reduced by the amount of benefits paid by
19 Medicare. For members or dependents who are eligible for
20 benefits under Social Security or the Railroad Retirement
21 system or who had sufficient Medicare-covered government
22 employment, benefits shall be reduced by the amount for which
23 the member or dependent is eligible under Medicare, except
24 that such reduction in benefits shall apply only to those
25 members or dependents who (1) first become eligible for such
26 Medicare coverage on or after the effective date of this

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1 amendatory Act of 1992; or (2) are Medicare-eligible members
2 or dependents of a local government unit which began
3 participation in the program on or after July 1, 1992; or (3)
4 remain eligible for, but no longer receive Medicare coverage
5 which they had been receiving on or after the effective date of
6 this amendatory Act of 1992. Premiums may be adjusted, where
7 applicable, to an amount deemed by the Director to be
8 reasonably consistent with any reduction of benefits.
9 (b) A member, not otherwise covered by this Act, who has
10 retired as a participating member under Article 2 of the
11 Illinois Pension Code but is ineligible for the retirement
12 annuity under Section 2-119 of the Illinois Pension Code,
13 shall pay the premiums for coverage, not exceeding the amount
14 paid by the State for the non-contributory coverage for other
15 members, under the group health benefits program under this
16 Act. The Director shall determine the premiums to be paid by a
17 member under this subsection (b).
18 (Source: P.A. 100-538, eff. 1-1-18.)
19 (5 ILCS 375/6.1) (from Ch. 127, par. 526.1)
20 Sec. 6.1. The program of health benefits may offer as an
21 alternative, available on an optional basis, coverage through
22 health maintenance organizations or other managed care
23 programs. That part of the premium for such coverage which is
24 in excess of the amount which would otherwise be paid by the
25 State for the program of health benefits shall be paid by the

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1 member who elects such alternative coverage and shall be
2 collected as provided for premiums for other optional
3 coverages, except as provided in the No Taxpayer Funding for
4 Abortion Act.
5 (Source: P.A. 102-19, eff. 7-1-21.)
6 Section 905. The Illinois Public Aid Code is amended by
7 changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
8 (305 ILCS 5/5-5)
9 Sec. 5-5. Medical services. The Illinois Department, by
10 rule, shall determine the quantity and quality of and the rate
11 of reimbursement for the medical assistance for which payment
12 will be authorized, and the medical services to be provided,
13 which may include all or part of the following: (1) inpatient
14 hospital services; (2) outpatient hospital services; (3) other
15 laboratory and X-ray services; (4) skilled nursing home
16 services; (5) physicians' services whether furnished in the
17 office, the patient's home, a hospital, a skilled nursing
18 home, or elsewhere; (6) medical care, or any other type of
19 remedial care furnished by licensed practitioners; (7) home
20 health care services; (8) private duty nursing service; (9)
21 clinic services; (10) dental services, including prevention
22 and treatment of periodontal disease and dental caries disease
23 for pregnant individuals, provided by an individual licensed
24 to practice dentistry or dental surgery; for purposes of this

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1 item (10), "dental services" means diagnostic, preventive, or
2 corrective procedures provided by or under the supervision of
3 a dentist in the practice of his or her profession; (11)
4 physical therapy and related services; (12) prescribed drugs,
5 dentures, and prosthetic devices; and eyeglasses prescribed by
6 a physician skilled in the diseases of the eye, or by an
7 optometrist, whichever the person may select; (13) other
8 diagnostic, screening, preventive, and rehabilitative
9 services, including to ensure that the individual's need for
10 intervention or treatment of mental disorders or substance use
11 disorders or co-occurring mental health and substance use
12 disorders is determined using a uniform screening, assessment,
13 and evaluation process inclusive of criteria, for children and
14 adults; for purposes of this item (13), a uniform screening,
15 assessment, and evaluation process refers to a process that
16 includes an appropriate evaluation and, as warranted, a
17 referral; "uniform" does not mean the use of a singular
18 instrument, tool, or process that all must utilize; (14)
19 transportation and such other expenses as may be necessary;
20 (15) medical treatment of sexual assault survivors, as defined
21 in Section 1a of the Sexual Assault Survivors Emergency
22 Treatment Act, for injuries sustained as a result of the
23 sexual assault, including examinations and laboratory tests to
24 discover evidence which may be used in criminal proceedings
25 arising from the sexual assault; (16) the diagnosis and
26 treatment of sickle cell anemia; (16.5) services performed by

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1 a chiropractic physician licensed under the Medical Practice
2 Act of 1987 and acting within the scope of his or her license,
3 including, but not limited to, chiropractic manipulative
4 treatment; and (17) any other medical care, and any other type
5 of remedial care recognized under the laws of this State,
6 except as provided in the No Taxpayer Funding for Abortion
7 Act. The Illinois Department, by rule, shall prohibit any
8 physician from providing medical assistance to anyone eligible
9 therefor under this Code where such physician has been found
10 guilty of performing an abortion procedure in a willful and
11 wanton manner upon a woman who was not pregnant at the time
12 such abortion procedure was performed. The term "any other
13 type of remedial care" shall include nursing care and nursing
14 home service for persons who rely on treatment by spiritual
15 means alone through prayer for healing.
16 Notwithstanding any other provision of this Section, a
17 comprehensive tobacco use cessation program that includes
18 purchasing prescription drugs or prescription medical devices
19 approved by the Food and Drug Administration shall be covered
20 under the medical assistance program under this Article for
21 persons who are otherwise eligible for assistance under this
22 Article.
23 Notwithstanding any other provision of this Code,
24 reproductive health care that is otherwise legal in Illinois
25 shall be covered under the medical assistance program for
26 persons who are otherwise eligible for medical assistance

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1 under this Article, except as provided in the No Taxpayer
2 Funding for Abortion Act.
3 Notwithstanding any other provision of this Section, all
4 tobacco cessation medications approved by the United States
5 Food and Drug Administration and all individual and group
6 tobacco cessation counseling services and telephone-based
7 counseling services and tobacco cessation medications provided
8 through the Illinois Tobacco Quitline shall be covered under
9 the medical assistance program for persons who are otherwise
10 eligible for assistance under this Article. The Department
11 shall comply with all federal requirements necessary to obtain
12 federal financial participation, as specified in 42 CFR
13 433.15(b)(7), for telephone-based counseling services provided
14 through the Illinois Tobacco Quitline, including, but not
15 limited to: (i) entering into a memorandum of understanding or
16 interagency agreement with the Department of Public Health, as
17 administrator of the Illinois Tobacco Quitline; and (ii)
18 developing a cost allocation plan for Medicaid-allowable
19 Illinois Tobacco Quitline services in accordance with 45 CFR
20 95.507. The Department shall submit the memorandum of
21 understanding or interagency agreement, the cost allocation
22 plan, and all other necessary documentation to the Centers for
23 Medicare and Medicaid Services for review and approval.
24 Coverage under this paragraph shall be contingent upon federal
25 approval.
26 Notwithstanding any other provision of this Code, the

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1 Illinois Department may not require, as a condition of payment
2 for any laboratory test authorized under this Article, that a
3 physician's handwritten signature appear on the laboratory
4 test order form. The Illinois Department may, however, impose
5 other appropriate requirements regarding laboratory test order
6 documentation.
7 Upon receipt of federal approval of an amendment to the
8 Illinois Title XIX State Plan for this purpose, the Department
9 shall authorize the Chicago Public Schools (CPS) to procure a
10 vendor or vendors to manufacture eyeglasses for individuals
11 enrolled in a school within the CPS system. CPS shall ensure
12 that its vendor or vendors are enrolled as providers in the
13 medical assistance program and in any capitated Medicaid
14 managed care entity (MCE) serving individuals enrolled in a
15 school within the CPS system. Under any contract procured
16 under this provision, the vendor or vendors must serve only
17 individuals enrolled in a school within the CPS system. Claims
18 for services provided by CPS's vendor or vendors to recipients
19 of benefits in the medical assistance program under this Code,
20 the Children's Health Insurance Program, or the Covering ALL
21 KIDS Health Insurance Program shall be submitted to the
22 Department or the MCE in which the individual is enrolled for
23 payment and shall be reimbursed at the Department's or the
24 MCE's established rates or rate methodologies for eyeglasses.
25 On and after July 1, 2012, the Department of Healthcare
26 and Family Services may provide the following services to

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1 persons eligible for assistance under this Article who are
2 participating in education, training or employment programs
3 operated by the Department of Human Services as successor to
4 the Department of Public Aid:
5 (1) dental services provided by or under the
6 supervision of a dentist; and
7 (2) eyeglasses prescribed by a physician skilled in
8 the diseases of the eye, or by an optometrist, whichever
9 the person may select.
10 On and after July 1, 2018, the Department of Healthcare
11 and Family Services shall provide dental services to any adult
12 who is otherwise eligible for assistance under the medical
13 assistance program. As used in this paragraph, "dental
14 services" means diagnostic, preventative, restorative, or
15 corrective procedures, including procedures and services for
16 the prevention and treatment of periodontal disease and dental
17 caries disease, provided by an individual who is licensed to
18 practice dentistry or dental surgery or who is under the
19 supervision of a dentist in the practice of his or her
20 profession.
21 On and after July 1, 2018, targeted dental services, as
22 set forth in Exhibit D of the Consent Decree entered by the
23 United States District Court for the Northern District of
24 Illinois, Eastern Division, in the matter of Memisovski v.
25 Maram, Case No. 92 C 1982, that are provided to adults under
26 the medical assistance program shall be established at no less

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1 than the rates set forth in the "New Rate" column in Exhibit D
2 of the Consent Decree for targeted dental services that are
3 provided to persons under the age of 18 under the medical
4 assistance program.
5 Notwithstanding any other provision of this Code and
6 subject to federal approval, the Department may adopt rules to
7 allow a dentist who is volunteering his or her service at no
8 cost to render dental services through an enrolled
9 not-for-profit health clinic without the dentist personally
10 enrolling as a participating provider in the medical
11 assistance program. A not-for-profit health clinic shall
12 include a public health clinic or Federally Qualified Health
13 Center or other enrolled provider, as determined by the
14 Department, through which dental services covered under this
15 Section are performed. The Department shall establish a
16 process for payment of claims for reimbursement for covered
17 dental services rendered under this provision.
18 On and after January 1, 2022, the Department of Healthcare
19 and Family Services shall administer and regulate a
20 school-based dental program that allows for the out-of-office
21 delivery of preventative dental services in a school setting
22 to children under 19 years of age. The Department shall
23 establish, by rule, guidelines for participation by providers
24 and set requirements for follow-up referral care based on the
25 requirements established in the Dental Office Reference Manual
26 published by the Department that establishes the requirements

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1 for dentists participating in the All Kids Dental School
2 Program. Every effort shall be made by the Department when
3 developing the program requirements to consider the different
4 geographic differences of both urban and rural areas of the
5 State for initial treatment and necessary follow-up care. No
6 provider shall be charged a fee by any unit of local government
7 to participate in the school-based dental program administered
8 by the Department. Nothing in this paragraph shall be
9 construed to limit or preempt a home rule unit's or school
10 district's authority to establish, change, or administer a
11 school-based dental program in addition to, or independent of,
12 the school-based dental program administered by the
13 Department.
14 The Illinois Department, by rule, may distinguish and
15 classify the medical services to be provided only in
16 accordance with the classes of persons designated in Section
17 5-2.
18 The Department of Healthcare and Family Services must
19 provide coverage and reimbursement for amino acid-based
20 elemental formulas, regardless of delivery method, for the
21 diagnosis and treatment of (i) eosinophilic disorders and (ii)
22 short bowel syndrome when the prescribing physician has issued
23 a written order stating that the amino acid-based elemental
24 formula is medically necessary.
25 The Illinois Department shall authorize the provision of,
26 and shall authorize payment for, screening by low-dose

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1 mammography for the presence of occult breast cancer for
2 individuals 35 years of age or older who are eligible for
3 medical assistance under this Article, as follows:
4 (A) A baseline mammogram for individuals 35 to 39
5 years of age.
6 (B) An annual mammogram for individuals 40 years of
7 age or older.
8 (C) A mammogram at the age and intervals considered
9 medically necessary by the individual's health care
10 provider for individuals under 40 years of age and having
11 a family history of breast cancer, prior personal history
12 of breast cancer, positive genetic testing, or other risk
13 factors.
14 (D) A comprehensive ultrasound screening and MRI of an
15 entire breast or breasts if a mammogram demonstrates
16 heterogeneous or dense breast tissue or when medically
17 necessary as determined by a physician licensed to
18 practice medicine in all of its branches.
19 (E) A screening MRI when medically necessary, as
20 determined by a physician licensed to practice medicine in
21 all of its branches.
22 (F) A diagnostic mammogram when medically necessary,
23 as determined by a physician licensed to practice medicine
24 in all its branches, advanced practice registered nurse,
25 or physician assistant.
26 The Department shall not impose a deductible, coinsurance,

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1 copayment, or any other cost-sharing requirement on the
2 coverage provided under this paragraph; except that this
3 sentence does not apply to coverage of diagnostic mammograms
4 to the extent such coverage would disqualify a high-deductible
5 health plan from eligibility for a health savings account
6 pursuant to Section 223 of the Internal Revenue Code (26
7 U.S.C. 223).
8 All screenings shall include a physical breast exam,
9 instruction on self-examination and information regarding the
10 frequency of self-examination and its value as a preventative
11 tool.
12 For purposes of this Section:
13 "Diagnostic mammogram" means a mammogram obtained using
14 diagnostic mammography.
15 "Diagnostic mammography" means a method of screening that
16 is designed to evaluate an abnormality in a breast, including
17 an abnormality seen or suspected on a screening mammogram or a
18 subjective or objective abnormality otherwise detected in the
19 breast.
20 "Low-dose mammography" means the x-ray examination of the
21 breast using equipment dedicated specifically for mammography,
22 including the x-ray tube, filter, compression device, and
23 image receptor, with an average radiation exposure delivery of
24 less than one rad per breast for 2 views of an average size
25 breast. The term also includes digital mammography and
26 includes breast tomosynthesis.

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1 "Breast tomosynthesis" means a radiologic procedure that
2 involves the acquisition of projection images over the
3 stationary breast to produce cross-sectional digital
4 three-dimensional images of the breast.
5 If, at any time, the Secretary of the United States
6 Department of Health and Human Services, or its successor
7 agency, promulgates rules or regulations to be published in
8 the Federal Register or publishes a comment in the Federal
9 Register or issues an opinion, guidance, or other action that
10 would require the State, pursuant to any provision of the
11 Patient Protection and Affordable Care Act (Public Law
12 111-148), including, but not limited to, 42 U.S.C.
13 18031(d)(3)(B) or any successor provision, to defray the cost
14 of any coverage for breast tomosynthesis outlined in this
15 paragraph, then the requirement that an insurer cover breast
16 tomosynthesis is inoperative other than any such coverage
17 authorized under Section 1902 of the Social Security Act, 42
18 U.S.C. 1396a, and the State shall not assume any obligation
19 for the cost of coverage for breast tomosynthesis set forth in
20 this paragraph.
21 On and after January 1, 2016, the Department shall ensure
22 that all networks of care for adult clients of the Department
23 include access to at least one breast imaging Center of
24 Imaging Excellence as certified by the American College of
25 Radiology.
26 On and after January 1, 2012, providers participating in a

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1 quality improvement program approved by the Department shall
2 be reimbursed for screening and diagnostic mammography at the
3 same rate as the Medicare program's rates, including the
4 increased reimbursement for digital mammography and, after
5 January 1, 2023 (the effective date of Public Act 102-1018),
6 breast tomosynthesis.
7 The Department shall convene an expert panel including
8 representatives of hospitals, free-standing mammography
9 facilities, and doctors, including radiologists, to establish
10 quality standards for mammography.
11 On and after January 1, 2017, providers participating in a
12 breast cancer treatment quality improvement program approved
13 by the Department shall be reimbursed for breast cancer
14 treatment at a rate that is no lower than 95% of the Medicare
15 program's rates for the data elements included in the breast
16 cancer treatment quality program.
17 The Department shall convene an expert panel, including
18 representatives of hospitals, free-standing breast cancer
19 treatment centers, breast cancer quality organizations, and
20 doctors, including breast surgeons, reconstructive breast
21 surgeons, oncologists, and primary care providers to establish
22 quality standards for breast cancer treatment.
23 Subject to federal approval, the Department shall
24 establish a rate methodology for mammography at federally
25 qualified health centers and other encounter-rate clinics.
26 These clinics or centers may also collaborate with other

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1 hospital-based mammography facilities. By January 1, 2016, the
2 Department shall report to the General Assembly on the status
3 of the provision set forth in this paragraph.
4 The Department shall establish a methodology to remind
5 individuals who are age-appropriate for screening mammography,
6 but who have not received a mammogram within the previous 18
7 months, of the importance and benefit of screening
8 mammography. The Department shall work with experts in breast
9 cancer outreach and patient navigation to optimize these
10 reminders and shall establish a methodology for evaluating
11 their effectiveness and modifying the methodology based on the
12 evaluation.
13 The Department shall establish a performance goal for
14 primary care providers with respect to their female patients
15 over age 40 receiving an annual mammogram. This performance
16 goal shall be used to provide additional reimbursement in the
17 form of a quality performance bonus to primary care providers
18 who meet that goal.
19 The Department shall devise a means of case-managing or
20 patient navigation for beneficiaries diagnosed with breast
21 cancer. This program shall initially operate as a pilot
22 program in areas of the State with the highest incidence of
23 mortality related to breast cancer. At least one pilot program
24 site shall be in the metropolitan Chicago area and at least one
25 site shall be outside the metropolitan Chicago area. On or
26 after July 1, 2016, the pilot program shall be expanded to

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1 include one site in western Illinois, one site in southern
2 Illinois, one site in central Illinois, and 4 sites within
3 metropolitan Chicago. An evaluation of the pilot program shall
4 be carried out measuring health outcomes and cost of care for
5 those served by the pilot program compared to similarly
6 situated patients who are not served by the pilot program.
7 The Department shall require all networks of care to
8 develop a means either internally or by contract with experts
9 in navigation and community outreach to navigate cancer
10 patients to comprehensive care in a timely fashion. The
11 Department shall require all networks of care to include
12 access for patients diagnosed with cancer to at least one
13 academic commission on cancer-accredited cancer program as an
14 in-network covered benefit.
15 The Department shall provide coverage and reimbursement
16 for a human papillomavirus (HPV) vaccine that is approved for
17 marketing by the federal Food and Drug Administration for all
18 persons between the ages of 9 and 45. Subject to federal
19 approval, the Department shall provide coverage and
20 reimbursement for a human papillomavirus (HPV) vaccine for
21 persons of the age of 46 and above who have been diagnosed with
22 cervical dysplasia with a high risk of recurrence or
23 progression. The Department shall disallow any
24 preauthorization requirements for the administration of the
25 human papillomavirus (HPV) vaccine.
26 On or after July 1, 2022, individuals who are otherwise

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1 eligible for medical assistance under this Article shall
2 receive coverage for perinatal depression screenings for the
3 12-month period beginning on the last day of their pregnancy.
4 Medical assistance coverage under this paragraph shall be
5 conditioned on the use of a screening instrument approved by
6 the Department.
7 Any medical or health care provider shall immediately
8 recommend, to any pregnant individual who is being provided
9 prenatal services and is suspected of having a substance use
10 disorder as defined in the Substance Use Disorder Act,
11 referral to a local substance use disorder treatment program
12 licensed by the Department of Human Services or to a licensed
13 hospital which provides substance abuse treatment services.
14 The Department of Healthcare and Family Services shall assure
15 coverage for the cost of treatment of the drug abuse or
16 addiction for pregnant recipients in accordance with the
17 Illinois Medicaid Program in conjunction with the Department
18 of Human Services.
19 All medical providers providing medical assistance to
20 pregnant individuals under this Code shall receive information
21 from the Department on the availability of services under any
22 program providing case management services for addicted
23 individuals, including information on appropriate referrals
24 for other social services that may be needed by addicted
25 individuals in addition to treatment for addiction.
26 The Illinois Department, in cooperation with the

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1 Departments of Human Services (as successor to the Department
2 of Alcoholism and Substance Abuse) and Public Health, through
3 a public awareness campaign, may provide information
4 concerning treatment for alcoholism and drug abuse and
5 addiction, prenatal health care, and other pertinent programs
6 directed at reducing the number of drug-affected infants born
7 to recipients of medical assistance.
8 Neither the Department of Healthcare and Family Services
9 nor the Department of Human Services shall sanction the
10 recipient solely on the basis of the recipient's substance
11 abuse.
12 The Illinois Department shall establish such regulations
13 governing the dispensing of health services under this Article
14 as it shall deem appropriate. The Department should seek the
15 advice of formal professional advisory committees appointed by
16 the Director of the Illinois Department for the purpose of
17 providing regular advice on policy and administrative matters,
18 information dissemination and educational activities for
19 medical and health care providers, and consistency in
20 procedures to the Illinois Department.
21 The Illinois Department may develop and contract with
22 Partnerships of medical providers to arrange medical services
23 for persons eligible under Section 5-2 of this Code.
24 Implementation of this Section may be by demonstration
25 projects in certain geographic areas. The Partnership shall be
26 represented by a sponsor organization. The Department, by

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1 rule, shall develop qualifications for sponsors of
2 Partnerships. Nothing in this Section shall be construed to
3 require that the sponsor organization be a medical
4 organization.
5 The sponsor must negotiate formal written contracts with
6 medical providers for physician services, inpatient and
7 outpatient hospital care, home health services, treatment for
8 alcoholism and substance abuse, and other services determined
9 necessary by the Illinois Department by rule for delivery by
10 Partnerships. Physician services must include prenatal and
11 obstetrical care. The Illinois Department shall reimburse
12 medical services delivered by Partnership providers to clients
13 in target areas according to provisions of this Article and
14 the Illinois Health Finance Reform Act, except that:
15 (1) Physicians participating in a Partnership and
16 providing certain services, which shall be determined by
17 the Illinois Department, to persons in areas covered by
18 the Partnership may receive an additional surcharge for
19 such services.
20 (2) The Department may elect to consider and negotiate
21 financial incentives to encourage the development of
22 Partnerships and the efficient delivery of medical care.
23 (3) Persons receiving medical services through
24 Partnerships may receive medical and case management
25 services above the level usually offered through the
26 medical assistance program.

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1 Medical providers shall be required to meet certain
2 qualifications to participate in Partnerships to ensure the
3 delivery of high quality medical services. These
4 qualifications shall be determined by rule of the Illinois
5 Department and may be higher than qualifications for
6 participation in the medical assistance program. Partnership
7 sponsors may prescribe reasonable additional qualifications
8 for participation by medical providers, only with the prior
9 written approval of the Illinois Department.
10 Nothing in this Section shall limit the free choice of
11 practitioners, hospitals, and other providers of medical
12 services by clients. In order to ensure patient freedom of
13 choice, the Illinois Department shall immediately promulgate
14 all rules and take all other necessary actions so that
15 provided services may be accessed from therapeutically
16 certified optometrists to the full extent of the Illinois
17 Optometric Practice Act of 1987 without discriminating between
18 service providers.
19 The Department shall apply for a waiver from the United
20 States Health Care Financing Administration to allow for the
21 implementation of Partnerships under this Section.
22 The Illinois Department shall require health care
23 providers to maintain records that document the medical care
24 and services provided to recipients of Medical Assistance
25 under this Article. Such records must be retained for a period
26 of not less than 6 years from the date of service or as

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1 provided by applicable State law, whichever period is longer,
2 except that if an audit is initiated within the required
3 retention period then the records must be retained until the
4 audit is completed and every exception is resolved. The
5 Illinois Department shall require health care providers to
6 make available, when authorized by the patient, in writing,
7 the medical records in a timely fashion to other health care
8 providers who are treating or serving persons eligible for
9 Medical Assistance under this Article. All dispensers of
10 medical services shall be required to maintain and retain
11 business and professional records sufficient to fully and
12 accurately document the nature, scope, details and receipt of
13 the health care provided to persons eligible for medical
14 assistance under this Code, in accordance with regulations
15 promulgated by the Illinois Department. The rules and
16 regulations shall require that proof of the receipt of
17 prescription drugs, dentures, prosthetic devices and
18 eyeglasses by eligible persons under this Section accompany
19 each claim for reimbursement submitted by the dispenser of
20 such medical services. No such claims for reimbursement shall
21 be approved for payment by the Illinois Department without
22 such proof of receipt, unless the Illinois Department shall
23 have put into effect and shall be operating a system of
24 post-payment audit and review which shall, on a sampling
25 basis, be deemed adequate by the Illinois Department to assure
26 that such drugs, dentures, prosthetic devices and eyeglasses

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1 for which payment is being made are actually being received by
2 eligible recipients. Within 90 days after September 16, 1984
3 (the effective date of Public Act 83-1439), the Illinois
4 Department shall establish a current list of acquisition costs
5 for all prosthetic devices and any other items recognized as
6 medical equipment and supplies reimbursable under this Article
7 and shall update such list on a quarterly basis, except that
8 the acquisition costs of all prescription drugs shall be
9 updated no less frequently than every 30 days as required by
10 Section 5-5.12.
11 The rules and regulations of the Illinois Department shall
12 require that a written statement including the required
13 opinion of a physician shall accompany any claim for
14 reimbursement for abortions or induced miscarriages or
15 premature births. This statement shall indicate what
16 procedures were used in providing such medical services.
17 Notwithstanding any other law to the contrary, the
18 Illinois Department shall, within 365 days after July 22, 2013
19 (the effective date of Public Act 98-104), establish
20 procedures to permit skilled care facilities licensed under
21 the Nursing Home Care Act to submit monthly billing claims for
22 reimbursement purposes. Following development of these
23 procedures, the Department shall, by July 1, 2016, test the
24 viability of the new system and implement any necessary
25 operational or structural changes to its information
26 technology platforms in order to allow for the direct

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

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1 regarding medical bills paid by the Illinois Department, which
2 inquiries could indicate potential existence of claims or
3 liens for the Illinois Department.
4 Enrollment of a vendor shall be subject to a provisional
5 period and shall be conditional for one year. During the
6 period of conditional enrollment, the Department may terminate
7 the vendor's eligibility to participate in, or may disenroll
8 the vendor from, the medical assistance program without cause.
9 Unless otherwise specified, such termination of eligibility or
10 disenrollment is not subject to the Department's hearing
11 process. However, a disenrolled vendor may reapply without
12 penalty.
13 The Department has the discretion to limit the conditional
14 enrollment period for vendors based upon the category of risk
15 of the vendor.
16 Prior to enrollment and during the conditional enrollment
17 period in the medical assistance program, all vendors shall be
18 subject to enhanced oversight, screening, and review based on
19 the risk of fraud, waste, and abuse that is posed by the
20 category of risk of the vendor. The Illinois Department shall
21 establish the procedures for oversight, screening, and review,
22 which may include, but need not be limited to: criminal and
23 financial background checks; fingerprinting; license,
24 certification, and authorization verifications; unscheduled or
25 unannounced site visits; database checks; prepayment audit
26 reviews; audits; payment caps; payment suspensions; and other

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1 screening as required by federal or State law.
2 The Department shall define or specify the following: (i)
3 by provider notice, the "category of risk of the vendor" for
4 each type of vendor, which shall take into account the level of
5 screening applicable to a particular category of vendor under
6 federal law and regulations; (ii) by rule or provider notice,
7 the maximum length of the conditional enrollment period for
8 each category of risk of the vendor; and (iii) by rule, the
9 hearing rights, if any, afforded to a vendor in each category
10 of risk of the vendor that is terminated or disenrolled during
11 the conditional enrollment period.
12 To be eligible for payment consideration, a vendor's
13 payment claim or bill, either as an initial claim or as a
14 resubmitted claim following prior rejection, must be received
15 by the Illinois Department, or its fiscal intermediary, no
16 later than 180 days after the latest date on the claim on which
17 medical goods or services were provided, with the following
18 exceptions:
19 (1) In the case of a provider whose enrollment is in
20 process by the Illinois Department, the 180-day period
21 shall not begin until the date on the written notice from
22 the Illinois Department that the provider enrollment is
23 complete.
24 (2) In the case of errors attributable to the Illinois
25 Department or any of its claims processing intermediaries
26 which result in an inability to receive, process, or

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1 adjudicate a claim, the 180-day period shall not begin
2 until the provider has been notified of the error.
3 (3) In the case of a provider for whom the Illinois
4 Department initiates the monthly billing process.
5 (4) In the case of a provider operated by a unit of
6 local government with a population exceeding 3,000,000
7 when local government funds finance federal participation
8 for claims payments.
9 For claims for services rendered during a period for which
10 a recipient received retroactive eligibility, claims must be
11 filed within 180 days after the Department determines the
12 applicant is eligible. For claims for which the Illinois
13 Department is not the primary payer, claims must be submitted
14 to the Illinois Department within 180 days after the final
15 adjudication by the primary payer.
16 In the case of long term care facilities, within 120
17 calendar days of receipt by the facility of required
18 prescreening information, new admissions with associated
19 admission documents shall be submitted through the Medical
20 Electronic Data Interchange (MEDI) or the Recipient
21 Eligibility Verification (REV) System or shall be submitted
22 directly to the Department of Human Services using required
23 admission forms. Effective September 1, 2014, admission
24 documents, including all prescreening information, must be
25 submitted through MEDI or REV. Confirmation numbers assigned
26 to an accepted transaction shall be retained by a facility to

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1 verify timely submittal. Once an admission transaction has
2 been completed, all resubmitted claims following prior
3 rejection are subject to receipt no later than 180 days after
4 the admission transaction has been completed.
5 Claims that are not submitted and received in compliance
6 with the foregoing requirements shall not be eligible for
7 payment under the medical assistance program, and the State
8 shall have no liability for payment of those claims.
9 To the extent consistent with applicable information and
10 privacy, security, and disclosure laws, State and federal
11 agencies and departments shall provide the Illinois Department
12 access to confidential and other information and data
13 necessary to perform eligibility and payment verifications and
14 other Illinois Department functions. This includes, but is not
15 limited to: information pertaining to licensure;
16 certification; earnings; immigration status; citizenship; wage
17 reporting; unearned and earned income; pension income;
18 employment; supplemental security income; social security
19 numbers; National Provider Identifier (NPI) numbers; the
20 National Practitioner Data Bank (NPDB); program and agency
21 exclusions; taxpayer identification numbers; tax delinquency;
22 corporate information; and death records.
23 The Illinois Department shall enter into agreements with
24 State agencies and departments, and is authorized to enter
25 into agreements with federal agencies and departments, under
26 which such agencies and departments shall share data necessary

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1 for medical assistance program integrity functions and
2 oversight. The Illinois Department shall develop, in
3 cooperation with other State departments and agencies, and in
4 compliance with applicable federal laws and regulations,
5 appropriate and effective methods to share such data. At a
6 minimum, and to the extent necessary to provide data sharing,
7 the Illinois Department shall enter into agreements with State
8 agencies and departments, and is authorized to enter into
9 agreements with federal agencies and departments, including,
10 but not limited to: the Secretary of State; the Department of
11 Revenue; the Department of Public Health; the Department of
12 Human Services; and the Department of Financial and
13 Professional Regulation.
14 Beginning in fiscal year 2013, the Illinois Department
15 shall set forth a request for information to identify the
16 benefits of a pre-payment, post-adjudication, and post-edit
17 claims system with the goals of streamlining claims processing
18 and provider reimbursement, reducing the number of pending or
19 rejected claims, and helping to ensure a more transparent
20 adjudication process through the utilization of: (i) provider
21 data verification and provider screening technology; and (ii)
22 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
23 post-adjudicated predictive modeling with an integrated case
24 management system with link analysis. Such a request for
25 information shall not be considered as a request for proposal
26 or as an obligation on the part of the Illinois Department to

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1 take any action or acquire any products or services.
2 The Illinois Department shall establish policies,
3 procedures, standards and criteria by rule for the
4 acquisition, repair and replacement of orthotic and prosthetic
5 devices and durable medical equipment. Such rules shall
6 provide, but not be limited to, the following services: (1)
7 immediate repair or replacement of such devices by recipients;
8 and (2) rental, lease, purchase or lease-purchase of durable
9 medical equipment in a cost-effective manner, taking into
10 consideration the recipient's medical prognosis, the extent of
11 the recipient's needs, and the requirements and costs for
12 maintaining such equipment. Subject to prior approval, such
13 rules shall enable a recipient to temporarily acquire and use
14 alternative or substitute devices or equipment pending repairs
15 or replacements of any device or equipment previously
16 authorized for such recipient by the Department.
17 Notwithstanding any provision of Section 5-5f to the contrary,
18 the Department may, by rule, exempt certain replacement
19 wheelchair parts from prior approval and, for wheelchairs,
20 wheelchair parts, wheelchair accessories, and related seating
21 and positioning items, determine the wholesale price by
22 methods other than actual acquisition costs.
23 The Department shall require, by rule, all providers of
24 durable medical equipment to be accredited by an accreditation
25 organization approved by the federal Centers for Medicare and
26 Medicaid Services and recognized by the Department in order to

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1 bill the Department for providing durable medical equipment to
2 recipients. No later than 15 months after the effective date
3 of the rule adopted pursuant to this paragraph, all providers
4 must meet the accreditation requirement.
5 In order to promote environmental responsibility, meet the
6 needs of recipients and enrollees, and achieve significant
7 cost savings, the Department, or a managed care organization
8 under contract with the Department, may provide recipients or
9 managed care enrollees who have a prescription or Certificate
10 of Medical Necessity access to refurbished durable medical
11 equipment under this Section (excluding prosthetic and
12 orthotic devices as defined in the Orthotics, Prosthetics, and
13 Pedorthics Practice Act and complex rehabilitation technology
14 products and associated services) through the State's
15 assistive technology program's reutilization program, using
16 staff with the Assistive Technology Professional (ATP)
17 Certification if the refurbished durable medical equipment:
18 (i) is available; (ii) is less expensive, including shipping
19 costs, than new durable medical equipment of the same type;
20 (iii) is able to withstand at least 3 years of use; (iv) is
21 cleaned, disinfected, sterilized, and safe in accordance with
22 federal Food and Drug Administration regulations and guidance
23 governing the reprocessing of medical devices in health care
24 settings; and (v) equally meets the needs of the recipient or
25 enrollee. The reutilization program shall confirm that the
26 recipient or enrollee is not already in receipt of the same or

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1 similar equipment from another service provider, and that the
2 refurbished durable medical equipment equally meets the needs
3 of the recipient or enrollee. Nothing in this paragraph shall
4 be construed to limit recipient or enrollee choice to obtain
5 new durable medical equipment or place any additional prior
6 authorization conditions on enrollees of managed care
7 organizations.
8 The Department shall execute, relative to the nursing home
9 prescreening project, written inter-agency agreements with the
10 Department of Human Services and the Department on Aging, to
11 effect the following: (i) intake procedures and common
12 eligibility criteria for those persons who are receiving
13 non-institutional services; and (ii) the establishment and
14 development of non-institutional services in areas of the
15 State where they are not currently available or are
16 undeveloped; and (iii) notwithstanding any other provision of
17 law, subject to federal approval, on and after July 1, 2012, an
18 increase in the determination of need (DON) scores from 29 to
19 37 for applicants for institutional and home and
20 community-based long term care; if and only if federal
21 approval is not granted, the Department may, in conjunction
22 with other affected agencies, implement utilization controls
23 or changes in benefit packages to effectuate a similar savings
24 amount for this population; and (iv) no later than July 1,
25 2013, minimum level of care eligibility criteria for
26 institutional and home and community-based long term care; and

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1 (v) no later than October 1, 2013, establish procedures to
2 permit long term care providers access to eligibility scores
3 for individuals with an admission date who are seeking or
4 receiving services from the long term care provider. In order
5 to select the minimum level of care eligibility criteria, the
6 Governor shall establish a workgroup that includes affected
7 agency representatives and stakeholders representing the
8 institutional and home and community-based long term care
9 interests. This Section shall not restrict the Department from
10 implementing lower level of care eligibility criteria for
11 community-based services in circumstances where federal
12 approval has been granted.
13 The Illinois Department shall develop and operate, in
14 cooperation with other State Departments and agencies and in
15 compliance with applicable federal laws and regulations,
16 appropriate and effective systems of health care evaluation
17 and programs for monitoring of utilization of health care
18 services and facilities, as it affects persons eligible for
19 medical assistance under this Code.
20 The Illinois Department shall report annually to the
21 General Assembly, no later than the second Friday in April of
22 1979 and each year thereafter, in regard to:
23 (a) actual statistics and trends in utilization of
24 medical services by public aid recipients;
25 (b) actual statistics and trends in the provision of
26 the various medical services by medical vendors;

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1 (c) current rate structures and proposed changes in
2 those rate structures for the various medical vendors; and
3 (d) efforts at utilization review and control by the
4 Illinois Department.
5 The period covered by each report shall be the 3 years
6 ending on the June 30 prior to the report. The report shall
7 include suggested legislation for consideration by the General
8 Assembly. The requirement for reporting to the General
9 Assembly shall be satisfied by filing copies of the report as
10 required by Section 3.1 of the General Assembly Organization
11 Act, and filing such additional copies with the State
12 Government Report Distribution Center for the General Assembly
13 as is required under paragraph (t) of Section 7 of the State
14 Library Act.
15 Rulemaking authority to implement Public Act 95-1045, if
16 any, is conditioned on the rules being adopted in accordance
17 with all provisions of the Illinois Administrative Procedure
18 Act and all rules and procedures of the Joint Committee on
19 Administrative Rules; any purported rule not so adopted, for
20 whatever reason, is unauthorized.
21 On and after July 1, 2012, the Department shall reduce any
22 rate of reimbursement for services or other payments or alter
23 any methodologies authorized by this Code to reduce any rate
24 of reimbursement for services or other payments in accordance
25 with Section 5-5e.
26 Because kidney transplantation can be an appropriate,

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1 cost-effective alternative to renal dialysis when medically
2 necessary and notwithstanding the provisions of Section 1-11
3 of this Code, beginning October 1, 2014, the Department shall
4 cover kidney transplantation for noncitizens with end-stage
5 renal disease who are not eligible for comprehensive medical
6 benefits, who meet the residency requirements of Section 5-3
7 of this Code, and who would otherwise meet the financial
8 requirements of the appropriate class of eligible persons
9 under Section 5-2 of this Code. To qualify for coverage of
10 kidney transplantation, such person must be receiving
11 emergency renal dialysis services covered by the Department.
12 Providers under this Section shall be prior approved and
13 certified by the Department to perform kidney transplantation
14 and the services under this Section shall be limited to
15 services associated with kidney transplantation.
16 Notwithstanding any other provision of this Code to the
17 contrary, on or after July 1, 2015, all FDA approved forms of
18 medication assisted treatment prescribed for the treatment of
19 alcohol dependence or treatment of opioid dependence shall be
20 covered under both fee-for-service fee for service and managed
21 care medical assistance programs for persons who are otherwise
22 eligible for medical assistance under this Article and shall
23 not be subject to any (1) utilization control, other than
24 those established under the American Society of Addiction
25 Medicine patient placement criteria, (2) prior authorization
26 mandate, or (3) lifetime restriction limit mandate.

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1 On or after July 1, 2015, opioid antagonists prescribed
2 for the treatment of an opioid overdose, including the
3 medication product, administration devices, and any pharmacy
4 fees or hospital fees related to the dispensing, distribution,
5 and administration of the opioid antagonist, shall be covered
6 under the medical assistance program for persons who are
7 otherwise eligible for medical assistance under this Article.
8 As used in this Section, "opioid antagonist" means a drug that
9 binds to opioid receptors and blocks or inhibits the effect of
10 opioids acting on those receptors, including, but not limited
11 to, naloxone hydrochloride or any other similarly acting drug
12 approved by the U.S. Food and Drug Administration. The
13 Department shall not impose a copayment on the coverage
14 provided for naloxone hydrochloride under the medical
15 assistance program.
16 Upon federal approval, the Department shall provide
17 coverage and reimbursement for all drugs that are approved for
18 marketing by the federal Food and Drug Administration and that
19 are recommended by the federal Public Health Service or the
20 United States Centers for Disease Control and Prevention for
21 pre-exposure prophylaxis and related pre-exposure prophylaxis
22 services, including, but not limited to, HIV and sexually
23 transmitted infection screening, treatment for sexually
24 transmitted infections, medical monitoring, assorted labs, and
25 counseling to reduce the likelihood of HIV infection among
26 individuals who are not infected with HIV but who are at high

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1 risk of HIV infection.
2 A federally qualified health center, as defined in Section
3 1905(l)(2)(B) of the federal Social Security Act, shall be
4 reimbursed by the Department in accordance with the federally
5 qualified health center's encounter rate for services provided
6 to medical assistance recipients that are performed by a
7 dental hygienist, as defined under the Illinois Dental
8 Practice Act, working under the general supervision of a
9 dentist and employed by a federally qualified health center.
10 Within 90 days after October 8, 2021 (the effective date
11 of Public Act 102-665), the Department shall seek federal
12 approval of a State Plan amendment to expand coverage for
13 family planning services that includes presumptive eligibility
14 to individuals whose income is at or below 208% of the federal
15 poverty level. Coverage under this Section shall be effective
16 beginning no later than December 1, 2022.
17 Subject to approval by the federal Centers for Medicare
18 and Medicaid Services of a Title XIX State Plan amendment
19 electing the Program of All-Inclusive Care for the Elderly
20 (PACE) as a State Medicaid option, as provided for by Subtitle
21 I (commencing with Section 4801) of Title IV of the Balanced
22 Budget Act of 1997 (Public Law 105-33) and Part 460
23 (commencing with Section 460.2) of Subchapter E of Title 42 of
24 the Code of Federal Regulations, PACE program services shall
25 become a covered benefit of the medical assistance program,
26 subject to criteria established in accordance with all

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1 applicable laws.
2 Notwithstanding any other provision of this Code,
3 community-based pediatric palliative care from a trained
4 interdisciplinary team shall be covered under the medical
5 assistance program as provided in Section 15 of the Pediatric
6 Palliative Care Act.
7 Notwithstanding any other provision of this Code, within
8 12 months after June 2, 2022 (the effective date of Public Act
9 102-1037) and subject to federal approval, acupuncture
10 services performed by an acupuncturist licensed under the
11 Acupuncture Practice Act who is acting within the scope of his
12 or her license shall be covered under the medical assistance
13 program. The Department shall apply for any federal waiver or
14 State Plan amendment, if required, to implement this
15 paragraph. The Department may adopt any rules, including
16 standards and criteria, necessary to implement this paragraph.
17 Notwithstanding any other provision of this Code, the
18 medical assistance program shall, subject to appropriation and
19 federal approval, reimburse hospitals for costs associated
20 with a newborn screening test for the presence of
21 metachromatic leukodystrophy, as required under the Newborn
22 Metabolic Screening Act, at a rate not less than the fee
23 charged by the Department of Public Health. The Department
24 shall seek federal approval before the implementation of the
25 newborn screening test fees by the Department of Public
26 Health.

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1 Notwithstanding any other provision of this Code,
2 beginning on January 1, 2024, subject to federal approval,
3 cognitive assessment and care planning services provided to a
4 person who experiences signs or symptoms of cognitive
5 impairment, as defined by the Diagnostic and Statistical
6 Manual of Mental Disorders, Fifth Edition, shall be covered
7 under the medical assistance program for persons who are
8 otherwise eligible for medical assistance under this Article.
9 Notwithstanding any other provision of this Code,
10 medically necessary reconstructive services that are intended
11 to restore physical appearance shall be covered under the
12 medical assistance program for persons who are otherwise
13 eligible for medical assistance under this Article. As used in
14 this paragraph, "reconstructive services" means treatments
15 performed on structures of the body damaged by trauma to
16 restore physical appearance.
17 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
18 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
19 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
20 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
21 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
22 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
23 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
24 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
25 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
26 1-1-24; revised 12-15-23.)

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1 (305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
2 Sec. 5-8. Practitioners. In supplying medical assistance,
3 the Illinois Department may provide for the legally authorized
4 services of (i) persons licensed under the Medical Practice
5 Act of 1987, as amended, except as hereafter in this Section
6 stated, whether under a general or limited license, (ii)
7 persons licensed under the Nurse Practice Act as advanced
8 practice registered nurses, regardless of whether or not the
9 persons have written collaborative agreements, (iii) persons
10 licensed or registered under other laws of this State to
11 provide dental, medical, pharmaceutical, optometric,
12 podiatric, or nursing services, or other remedial care
13 recognized under State law, (iv) persons licensed under other
14 laws of this State as a clinical social worker, and (v) persons
15 licensed under other laws of this State as physician
16 assistants. The Department shall adopt rules, no later than 90
17 days after January 1, 2017 (the effective date of Public Act
18 99-621), for the legally authorized services of persons
19 licensed under other laws of this State as a clinical social
20 worker. The Department shall provide for the legally
21 authorized services of persons licensed under the Professional
22 Counselor and Clinical Professional Counselor Licensing and
23 Practice Act as clinical professional counselors and for the
24 legally authorized services of persons licensed under the
25 Marriage and Family Therapy Licensing Act as marriage and

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1 family therapists. The Department may not provide for legally
2 authorized services of any physician who has been convicted of
3 having performed an abortion procedure in a willful and wanton
4 manner on a woman who was not pregnant at the time such
5 abortion procedure was performed. The utilization of the
6 services of persons engaged in the treatment or care of the
7 sick, which persons are not required to be licensed or
8 registered under the laws of this State, is not prohibited by
9 this Section.
10 (Source: P.A. 102-43, eff. 7-6-21.)
11 (305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
12 Sec. 5-9. Choice of medical dispensers. Applicants and
13 recipients shall be entitled to free choice of those qualified
14 practitioners, hospitals, nursing homes, and other dispensers
15 of medical services meeting the requirements and complying
16 with the rules and regulations of the Illinois Department.
17 However, the Director of Healthcare and Family Services may,
18 after providing reasonable notice and opportunity for hearing,
19 deny, suspend or terminate any otherwise qualified person,
20 firm, corporation, association, agency, institution, or other
21 legal entity, from participation as a vendor of goods or
22 services under the medical assistance program authorized by
23 this Article if the Director finds such vendor of medical
24 services in violation of this Act or the policy or rules and
25 regulations issued pursuant to this Act. Any physician who has

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1 been convicted of performing an abortion procedure in a
2 willful and wanton manner upon a woman who was not pregnant at
3 the time such abortion procedure was performed shall be
4 automatically removed from the list of physicians qualified to
5 participate as a vendor of medical services under the medical
6 assistance program authorized by this Article.
7 (Source: P.A. 100-538, eff. 1-1-18.)
8 (305 ILCS 5/6-1) (from Ch. 23, par. 6-1)
9 Sec. 6-1. Eligibility requirements. Financial aid in
10 meeting basic maintenance requirements shall be given under
11 this Article to or in behalf of persons who meet the
12 eligibility conditions of Sections 6-1.1 through 6-1.10,
13 except as provided in the No Taxpayer Funding for Abortion
14 Act. In addition, each unit of local government subject to
15 this Article shall provide persons receiving financial aid in
16 meeting basic maintenance requirements with financial aid for
17 either (a) necessary treatment, care, and supplies required
18 because of illness or disability, or (b) acute medical
19 treatment, care, and supplies only. If a local governmental
20 unit elects to provide financial aid for acute medical
21 treatment, care, and supplies only, the general types of acute
22 medical treatment, care, and supplies for which financial aid
23 is provided shall be specified in the general assistance rules
24 of the local governmental unit, which rules shall provide that
25 financial aid is provided, at a minimum, for acute medical

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1 treatment, care, or supplies necessitated by a medical
2 condition for which prior approval or authorization of medical
3 treatment, care, or supplies is not required by the general
4 assistance rules of the Illinois Department.
5 (Source: P.A. 100-538, eff. 1-1-18.)
6 Section 910. The Problem Pregnancy Health Services and
7 Care Act is amended by changing Section 4-100 as follows:
8 (410 ILCS 230/4-100) (from Ch. 111 1/2, par. 4604-100)
9 Sec. 4-100. The Department may make grants to nonprofit
10 agencies and organizations which do not use such grants to
11 refer or counsel for, or perform, abortions and which
12 coordinate and establish linkages among services that will
13 further the purposes of this Act and, where appropriate, will
14 provide, supplement, or improve the quality of such services.
15 (Source: P.A. 100-538, eff. 1-1-18.)
16 Section 990. Application of Act; home rule powers.
17 (a) This Act applies to all State and local (including
18 home rule unit) laws, ordinances, policies, procedures,
19 practices, and governmental actions and their implementation,
20 whether statutory or otherwise and whether adopted before or
21 after the effective date of this Act.
22 (b) A home rule unit may not adopt any rule in a manner
23 inconsistent with this Act. This Act is a limitation under

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1 subsection (i) of Section 6 of Article VII of the Illinois
2 Constitution on the concurrent exercise by home rule units of
3 powers and functions exercised by the State.

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