Illinois Senate Bill SB3741 Latest Draft

                            Public Act 103-1040
SB3741 EnrolledLRB103 37781 RPS 67910 b SB3741 Enrolled LRB103 37781 RPS 67910 b
SB3741 Enrolled LRB103 37781 RPS 67910 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after January 1, 2022 (the effective date of
Public Act 102-579), every insurer that amends, delivers,
issues, or renews group accident and health policies providing
coverage for hospital or medical treatment or services for
illness on an expense-incurred basis shall provide coverage
for the medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions consistent
with the parity requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be
free to select the physician licensed to practice medicine in
all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Substance

 

SB3741 Enrolled LRB103 37781 RPS 67910 b


Use Disorder Act of his or her choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act up
to the limits of coverage, provided (i) the disorder or
condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his or her
profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Substance
Use Disorder Act, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker, licensed clinical professional counselor, licensed


marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act
has informed the patient of the desirability of the patient
conferring with the patient's primary care physician.
(4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the current edition of the
World Health Organization's International Classification of
Disease or that is listed in the most recent version of the
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental
health condition that occurs during pregnancy or during the
postpartum period and includes, but is not limited to,
postpartum depression.
(5) Medically necessary treatment and medical necessity
determinations shall be interpreted and made in a manner that
is consistent with and pursuant to subsections (h) through
(t).
(b)(1) (Blank).
(2) (Blank).
(2.5) (Blank).
(3) Unless otherwise prohibited by federal law and


consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance, a qualified health plan offered through the
health insurance marketplace, or a provider of treatment of
mental, emotional, nervous, or substance use disorders or
conditions shall furnish medical records or other necessary
data that substantiate that initial or continued treatment is
at all times medically necessary. An insurer shall provide a
mechanism for the timely review by a provider holding the same
license and practicing in the same specialty as the patient's
provider, who is unaffiliated with the insurer, jointly
selected by the patient (or the patient's next of kin or legal
representative if the patient is unable to act for himself or
herself), the patient's provider, and the insurer in the event
of a dispute between the insurer and patient's provider
regarding the medical necessity of a treatment proposed by a
patient's provider. If the reviewing provider determines the
treatment to be medically necessary, the insurer shall provide
reimbursement for the treatment. Future contractual or
employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in
this procedure. Nothing prevents the insured from agreeing in
writing to continue treatment at his or her expense. When
making a determination of the medical necessity for a
treatment modality for mental, emotional, nervous, or


substance use disorders or conditions, an insurer must make
the determination in a manner that is consistent with the
manner used to make that determination with respect to other
diseases or illnesses covered under the policy, including an
appeals process. Medical necessity determinations for
substance use disorders shall be made in accordance with
appropriate patient placement criteria established by the
American Society of Addiction Medicine. No additional criteria
may be used to make medical necessity determinations for
substance use disorders.
(4) A group health benefit plan amended, delivered,
issued, or renewed on or after January 1, 2019 (the effective
date of Public Act 100-1024) or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or substance use disorder or condition consistent
with the parity requirements of Section 370c.1 of this
Code; provided, however, that in each calendar year
coverage shall not be less than the following:
(i) 45 days of inpatient treatment; and
(ii) beginning on June 26, 2006 (the effective
date of Public Act 94-921), 60 visits for outpatient


treatment including group and individual outpatient
treatment; and
(iii) for plans or policies delivered, issued for
delivery, renewed, or modified after January 1, 2007
(the effective date of Public Act 94-906), 20
additional outpatient visits for speech therapy for
treatment of pervasive developmental disorders that
will be in addition to speech therapy provided
pursuant to item (ii) of this subparagraph (A); and
(B) may not include a lifetime limit on the number of
days of inpatient treatment or the number of outpatient
visits covered under the plan.
(C) (Blank).
(5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a
qualified health plan offered through the health insurance
marketplace may not count toward the number of outpatient
visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover
the outpatient visits under the same terms and conditions as
it covers outpatient visits for the treatment of physical
illness.
(5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after September 9, 2015
(the effective date of Public Act 99-480) shall offer coverage
for medically necessary acute treatment services and medically


necessary clinical stabilization services. The treating
provider shall base all treatment recommendations and the
health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for medication-assisted treatment in accordance
with the most current Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions established by
the American Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial
assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
"Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences,
relapse prevention, outreach to families and significant
others, and aftercare planning for individuals beginning to
engage in recovery from addiction.


(6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
(6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall not impose prior authorization requirements,
including limitations on dosage, other than those
established under the Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine,
on a prescription medication approved by the United States
Food and Drug Administration that is prescribed or
administered for the treatment of substance use disorders;
(B) shall not impose any step therapy requirements,
other than those established under the Treatment Criteria
for Addictive, Substance-Related, and Co-Occurring
Conditions established by the American Society of
Addiction Medicine, before authorizing coverage for a
prescription medication approved by the United States Food
and Drug Administration that is prescribed or administered
for the treatment of substance use disorders;
(C) shall place all prescription medications approved
by the United States Food and Drug Administration
prescribed or administered for the treatment of substance
use disorders on, for brand medications, the lowest tier


of the drug formulary developed and maintained by the
individual or group health benefit plan that covers brand
medications and, for generic medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers
generic medications; and
(D) shall not exclude coverage for a prescription
medication approved by the United States Food and Drug
Administration for the treatment of substance use
disorders and any associated counseling or wraparound
services on the grounds that such medications and services
were court ordered.
(7) (Blank).
(8) (Blank).
(9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
treatment shall include coverage for treatment in a
residential treatment center certified or licensed by the
Department of Public Health or the Department of Human
Services.
(c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
(d) With respect to a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace, the


Department and, with respect to medical assistance, the
Department of Healthcare and Family Services shall each
enforce the requirements of this Section and Sections 356z.23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance
or regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 and final regulations applying the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 to Medicaid managed care organizations, the
Children's Health Insurance Program, and alternative benefit
plans. Specifically, the Department and the Department of
Healthcare and Family Services shall take action:
(1) proactively ensuring compliance by individual and
group policies, including by requiring that insurers
submit comparative analyses, as set forth in paragraph (6)
of subsection (k) of Section 370c.1, demonstrating how
they design and apply nonquantitative treatment
limitations, both as written and in operation, for mental,
emotional, nervous, or substance use disorder or condition
benefits as compared to how they design and apply
nonquantitative treatment limitations, as written and in
operation, for medical and surgical benefits;
(2) evaluating all consumer or provider complaints


regarding mental, emotional, nervous, or substance use
disorder or condition coverage for possible parity
violations;
(3) performing parity compliance market conduct
examinations or, in the case of the Department of
Healthcare and Family Services, parity compliance audits
of individual and group plans and policies, including, but
not limited to, reviews of:
(A) nonquantitative treatment limitations,
including, but not limited to, prior authorization
requirements, concurrent review, retrospective review,
step therapy, network admission standards,
reimbursement rates, and geographic restrictions;
(B) denials of authorization, payment, and
coverage; and
(C) other specific criteria as may be determined
by the Department.
The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
The Director may adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of


accident and health insurance, or a qualified health plan
offered through the health insurance marketplace with
respect to mental health or substance use disorder
benefits (or health insurance coverage offered in
connection with the plan with respect to such benefits)
must be made available by the plan administrator (or the
health insurance issuer offering such coverage) to any
current or potential participant, beneficiary, or
contracting provider upon request.
(2) The reason for any denial under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage
offered in connection with such plan or policy) of
reimbursement or payment for services with respect to
mental, emotional, nervous, or substance use disorders or
conditions benefits in the case of any participant or
beneficiary must be made available within a reasonable
time and in a reasonable manner and in readily
understandable language by the plan administrator (or the
health insurance issuer offering such coverage) to the
participant or beneficiary upon request.
(f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois or which purport to provide coverage


for a resident of this State; and (2) State employee health
plans.
(g) (1) As used in this subsection:
"Benefits", with respect to insurers, means the benefits
provided for treatment services for inpatient and outpatient
treatment of substance use disorders or conditions at American
Society of Addiction Medicine levels of treatment 2.1
(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
(Clinically Managed Low-Intensity Residential), 3.3
(Clinically Managed Population-Specific High-Intensity
Residential), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Benefits", with respect to managed care organizations,
means the benefits provided for treatment services for
inpatient and outpatient treatment of substance use disorders
or conditions at American Society of Addiction Medicine levels
of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
Hospitalization), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Substance use disorder treatment provider or facility"
means a licensed physician, licensed psychologist, licensed
psychiatrist, licensed advanced practice registered nurse, or
licensed, certified, or otherwise State-approved facility or
provider of substance use disorder treatment.


(2) A group health insurance policy, an individual health
benefit plan, or qualified health plan that is offered through
the health insurance marketplace, small employer group health
plan, and large employer group health plan that is amended,
delivered, issued, executed, or renewed in this State, or
approved for issuance or renewal in this State, on or after
January 1, 2019 (the effective date of Public Act 100-1023)
shall comply with the requirements of this Section and Section
370c.1. The services for the treatment and the ongoing
assessment of the patient's progress in treatment shall follow
the requirements of 77 Ill. Adm. Code 2060.
(3) Prior authorization shall not be utilized for the
benefits under this subsection. The substance use disorder
treatment provider or facility shall notify the insurer of the
initiation of treatment. For an insurer that is not a managed
care organization, the substance use disorder treatment
provider or facility notification shall occur for the
initiation of treatment of the covered person within 2
business days. For managed care organizations, the substance
use disorder treatment provider or facility notification shall
occur in accordance with the protocol set forth in the
provider agreement for initiation of treatment within 24
hours. If the managed care organization is not capable of
accepting the notification in accordance with the contractual
protocol during the 24-hour period following admission, the
substance use disorder treatment provider or facility shall


have one additional business day to provide the notification
to the appropriate managed care organization. Treatment plans
shall be developed in accordance with the requirements and
timeframes established in 77 Ill. Adm. Code 2060. If the
substance use disorder treatment provider or facility fails to
notify the insurer of the initiation of treatment in
accordance with these provisions, the insurer may follow its
normal prior authorization processes.
(4) For an insurer that is not a managed care
organization, if an insurer determines that benefits are no
longer medically necessary, the insurer shall notify the
covered person, the covered person's authorized
representative, if any, and the covered person's health care
provider in writing of the covered person's right to request
an external review pursuant to the Health Carrier External
Review Act. The notification shall occur within 24 hours
following the adverse determination.
Pursuant to the requirements of the Health Carrier
External Review Act, the covered person or the covered
person's authorized representative may request an expedited
external review. An expedited external review may not occur if
the substance use disorder treatment provider or facility
determines that continued treatment is no longer medically
necessary.
If an expedited external review request meets the criteria
of the Health Carrier External Review Act, an independent


review organization shall make a final determination of
medical necessity within 72 hours. If an independent review
organization upholds an adverse determination, an insurer
shall remain responsible to provide coverage of benefits
through the day following the determination of the independent
review organization. A decision to reverse an adverse
determination shall comply with the Health Carrier External
Review Act.
(5) The substance use disorder treatment provider or
facility shall provide the insurer with 7 business days'
advance notice of the planned discharge of the patient from
the substance use disorder treatment provider or facility and
notice on the day that the patient is discharged from the
substance use disorder treatment provider or facility.
(6) The benefits required by this subsection shall be
provided to all covered persons with a diagnosis of substance
use disorder or conditions. The presence of additional related
or unrelated diagnoses shall not be a basis to reduce or deny
the benefits required by this subsection.
(7) Nothing in this subsection shall be construed to
require an insurer to provide coverage for any of the benefits
in this subsection.
(h) As used in this Section:
"Generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care" means
standards of care and clinical practice that are generally


recognized by health care providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, social work, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
reflecting generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
"Medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions" means a
service or product addressing the specific needs of that
patient, for the purpose of screening, preventing, diagnosing,
managing, or treating an illness, injury, or condition or its
symptoms and comorbidities, including minimizing the
progression of an illness, injury, or condition or its
symptoms and comorbidities in a manner that is all of the
following:
(1) in accordance with the generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care;
(2) clinically appropriate in terms of type,


frequency, extent, site, and duration; and
(3) not primarily for the economic benefit of the
insurer, purchaser, or for the convenience of the patient,
treating physician, or other health care provider.
"Utilization review" means either of the following:
(1) prospectively, retrospectively, or concurrently
reviewing and approving, modifying, delaying, or denying,
based in whole or in part on medical necessity, requests
by health care providers, insureds, or their authorized
representatives for coverage of health care services
before, retrospectively, or concurrently with the
provision of health care services to insureds.
(2) evaluating the medical necessity, appropriateness,
level of care, service intensity, efficacy, or efficiency
of health care services, benefits, procedures, or
settings, under any circumstances, to determine whether a
health care service or benefit subject to a medical
necessity coverage requirement in an insurance policy is
covered as medically necessary for an insured.
"Utilization review criteria" means patient placement
criteria or any criteria, standards, protocols, or guidelines
used by an insurer to conduct utilization review.
(i)(1) Every insurer that amends, delivers, issues, or
renews a group or individual policy of accident and health
insurance or a qualified health plan offered through the
health insurance marketplace in this State and Medicaid


managed care organizations providing coverage for hospital or
medical treatment on or after January 1, 2023 shall, pursuant
to subsections (h) through (s), provide coverage for medically
necessary treatment of mental, emotional, nervous, or
substance use disorders or conditions.
(2) An insurer shall not set a specific limit on the
duration of benefits or coverage of medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions or limit coverage only to alleviation
of the insured's current symptoms.
(3) All medical necessity determinations made by the
insurer concerning service intensity, level of care placement,
continued stay, and transfer or discharge of insureds
diagnosed with mental, emotional, nervous, or substance use
disorders or conditions shall be conducted in accordance with
the requirements of subsections (k) through (u).
(4) An insurer that authorizes a specific type of
treatment by a provider pursuant to this Section shall not
rescind or modify the authorization after that provider
renders the health care service in good faith and pursuant to
this authorization for any reason, including, but not limited
to, the insurer's subsequent cancellation or modification of
the insured's or policyholder's contract, or the insured's or
policyholder's eligibility. Nothing in this Section shall
require the insurer to cover a treatment when the
authorization was granted based on a material


misrepresentation by the insured, the policyholder, or the
provider. Nothing in this Section shall require Medicaid
managed care organizations to pay for services if the
individual was not eligible for Medicaid at the time the
service was rendered. Nothing in this Section shall require an
insurer to pay for services if the individual was not the
insurer's enrollee at the time services were rendered. As used
in this paragraph, "material" means a fact or situation that
is not merely technical in nature and results in or could
result in a substantial change in the situation.
(j) An insurer shall not limit benefits or coverage for
medically necessary services on the basis that those services
should be or could be covered by a public entitlement program,
including, but not limited to, special education or an
individualized education program, Medicaid, Medicare,
Supplemental Security Income, or Social Security Disability
Insurance, and shall not include or enforce a contract term
that excludes otherwise covered benefits on the basis that
those services should be or could be covered by a public
entitlement program. Nothing in this subsection shall be
construed to require an insurer to cover benefits that have
been authorized and provided for a covered person by a public
entitlement program. Medicaid managed care organizations are
not subject to this subsection.
(k) An insurer shall base any medical necessity
determination or the utilization review criteria that the


insurer, and any entity acting on the insurer's behalf,
applies to determine the medical necessity of health care
services and benefits for the diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions on current generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care. All denials and appeals shall be
reviewed by a professional with experience or expertise
comparable to the provider requesting the authorization.
(l) For medical necessity determinations relating to level
of care placement, continued stay, and transfer or discharge
of insureds diagnosed with mental, emotional, and nervous
disorders or conditions, an insurer shall apply the patient
placement criteria set forth in the most recent version of the
treatment criteria developed by an unaffiliated nonprofit
professional association for the relevant clinical specialty
or, for Medicaid managed care organizations, patient placement
criteria determined by the Department of Healthcare and Family
Services that are consistent with generally accepted standards
of mental, emotional, nervous or substance use disorder or
condition care. Pursuant to subsection (b), in conducting
utilization review of all covered services and benefits for
the diagnosis, prevention, and treatment of substance use
disorders an insurer shall use the most recent edition of the
patient placement criteria established by the American Society
of Addiction Medicine.


(m) For medical necessity determinations relating to level
of care placement, continued stay, and transfer or discharge
that are within the scope of the sources specified in
subsection (l), an insurer shall not apply different,
additional, conflicting, or more restrictive utilization
review criteria than the criteria set forth in those sources.
For all level of care placement decisions, the insurer shall
authorize placement at the level of care consistent with the
assessment of the insured using the relevant patient placement
criteria as specified in subsection (l). If that level of
placement is not available, the insurer shall authorize the
next higher level of care. In the event of disagreement, the
insurer shall provide full detail of its assessment using the
relevant criteria as specified in subsection (l) to the
provider of the service and the patient.
Nothing in this subsection or subsection (l) prohibits an
insurer from applying utilization review criteria that were
developed in accordance with subsection (k) to health care
services and benefits for mental, emotional, and nervous
disorders or conditions that are not related to medical
necessity determinations for level of care placement,
continued stay, and transfer or discharge. If an insurer
purchases or licenses utilization review criteria pursuant to
this subsection, the insurer shall verify and document before
use that the criteria were developed in accordance with
subsection (k).


(n) In conducting utilization review that is outside the
scope of the criteria as specified in subsection (l) or
relates to the advancements in technology or in the types or
levels of care that are not addressed in the most recent
versions of the sources specified in subsection (l), an
insurer shall conduct utilization review in accordance with
subsection (k).
(o) This Section does not in any way limit the rights of a
patient under the Medical Patient Rights Act.
(p) This Section does not in any way limit early and
periodic screening, diagnostic, and treatment benefits as
defined under 42 U.S.C. 1396d(r).
(q) To ensure the proper use of the criteria described in
subsection (l), every insurer shall do all of the following:
(1) Educate the insurer's staff, including any third
parties contracted with the insurer to review claims,
conduct utilization reviews, or make medical necessity
determinations about the utilization review criteria.
(2) Make the educational program available to other
stakeholders, including the insurer's participating or
contracted providers and potential participants,
beneficiaries, or covered lives. The education program
must be provided at least once a year, in-person or
digitally, or recordings of the education program must be
made available to the aforementioned stakeholders.
(3) Provide, at no cost, the utilization review


criteria and any training material or resources to
providers and insured patients upon request. For
utilization review criteria not concerning level of care
placement, continued stay, and transfer or discharge used
by the insurer pursuant to subsection (m), the insurer may
place the criteria on a secure, password-protected website
so long as the access requirements of the website do not
unreasonably restrict access to insureds or their
providers. No restrictions shall be placed upon the
insured's or treating provider's access right to
utilization review criteria obtained under this paragraph
at any point in time, including before an initial request
for authorization.
(4) Track, identify, and analyze how the utilization
review criteria are used to certify care, deny care, and
support the appeals process.
(5) Conduct interrater reliability testing to ensure
consistency in utilization review decision making that
covers how medical necessity decisions are made; this
assessment shall cover all aspects of utilization review
as defined in subsection (h).
(6) Run interrater reliability reports about how the
clinical guidelines are used in conjunction with the
utilization review process and parity compliance
activities.
(7) Achieve interrater reliability pass rates of at


least 90% and, if this threshold is not met, immediately
provide for the remediation of poor interrater reliability
and interrater reliability testing for all new staff
before they can conduct utilization review without
supervision.
(8) Maintain documentation of interrater reliability
testing and the remediation actions taken for those with
pass rates lower than 90% and submit to the Department of
Insurance or, in the case of Medicaid managed care
organizations, the Department of Healthcare and Family
Services the testing results and a summary of remedial
actions as part of parity compliance reporting set forth
in subsection (k) of Section 370c.1.
(r) This Section applies to all health care services and
benefits for the diagnosis, prevention, and treatment of
mental, emotional, nervous, or substance use disorders or
conditions covered by an insurance policy, including
prescription drugs.
(s) This Section applies to an insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace in this State
providing coverage for hospital or medical treatment and
conducts utilization review as defined in this Section,
including Medicaid managed care organizations, and any entity
or contracting provider that performs utilization review or


utilization management functions on an insurer's behalf.
(t) If the Director determines that an insurer has
violated this Section, the Director may, after appropriate
notice and opportunity for hearing, by order, assess a civil
penalty between $1,000 and $5,000 for each violation. Moneys
collected from penalties shall be deposited into the Parity
Advancement Fund established in subsection (i) of Section
370c.1.
(u) An insurer shall not adopt, impose, or enforce terms
in its policies or provider agreements, in writing or in
operation, that undermine, alter, or conflict with the
requirements of this Section.
(v) The provisions of this Section are severable. If any
provision of this Section or its application is held invalid,
that invalidity shall not affect other provisions or
applications that can be given effect without the invalid
provision or application.
(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
Section 10. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5)
Sec. 5-5. Medical services.  The Illinois Department, by
rule, shall determine the quantity and quality of and the rate


of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,


and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered


under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of


understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL


KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.


On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office


delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the


diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals under 40 years of age and having
a family history of breast cancer, prior personal history
of breast cancer, positive genetic testing, or other risk
factors.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in


all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the


breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.


On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018),
breast tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast


surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast


cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for


persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information


from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.


The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate


financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the


implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall


be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct


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


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


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


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


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


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


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


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


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


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


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


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


limitations on dosage.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among


individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,


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


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


1-1-24; revised 12-15-23.)