Illinois 2023-2024 Regular Session

Illinois House Bill HB5203 Latest Draft

Bill / Introduced Version 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.

 

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

 

 

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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