Illinois 2025-2026 Regular Session

Illinois House Bill HB1456 Compare Versions

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

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1456 Introduced , by Rep. Christopher "C.D." Davidsmeyer SYNOPSIS AS INTRODUCED: 5 ILCS 100/5-45.37 rep.305 ILCS 5/5-2 from Ch. 23, par. 5-2305 ILCS 5/5-5305 ILCS 5/12-4.35 Amends the Medical Assistance Article and the Administration Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to cover kidney transplantation services for noncitizens under the medical assistance program. Removes provisions permitting the Department to provide medical services to noncitizens 42 years of age and older. Removes a provision requiring the Department to cover immunosuppressive drugs and related services associated with post kidney transplant management for noncitizens. Removes provisions concerning the adoption of emergency rules and other matters regarding medical coverage or services for noncitizens. LRB104 07779 KTG 17824 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1456 Introduced , by Rep. Christopher "C.D." Davidsmeyer SYNOPSIS AS INTRODUCED: 5 ILCS 100/5-45.37 rep.305 ILCS 5/5-2 from Ch. 23, par. 5-2305 ILCS 5/5-5305 ILCS 5/12-4.35 5 ILCS 100/5-45.37 rep. 305 ILCS 5/5-2 from Ch. 23, par. 5-2 305 ILCS 5/5-5 305 ILCS 5/12-4.35 Amends the Medical Assistance Article and the Administration Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to cover kidney transplantation services for noncitizens under the medical assistance program. Removes provisions permitting the Department to provide medical services to noncitizens 42 years of age and older. Removes a provision requiring the Department to cover immunosuppressive drugs and related services associated with post kidney transplant management for noncitizens. Removes provisions concerning the adoption of emergency rules and other matters regarding medical coverage or services for noncitizens. LRB104 07779 KTG 17824 b LRB104 07779 KTG 17824 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1456 Introduced , by Rep. Christopher "C.D." Davidsmeyer SYNOPSIS AS INTRODUCED:
3	3	5 ILCS 100/5-45.37 rep.305 ILCS 5/5-2 from Ch. 23, par. 5-2305 ILCS 5/5-5305 ILCS 5/12-4.35 5 ILCS 100/5-45.37 rep. 305 ILCS 5/5-2 from Ch. 23, par. 5-2 305 ILCS 5/5-5 305 ILCS 5/12-4.35
4	4	5 ILCS 100/5-45.37 rep.
5	5	305 ILCS 5/5-2 from Ch. 23, par. 5-2
6	6	305 ILCS 5/5-5
7	7	305 ILCS 5/12-4.35
8	8	Amends the Medical Assistance Article and the Administration Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to cover kidney transplantation services for noncitizens under the medical assistance program. Removes provisions permitting the Department to provide medical services to noncitizens 42 years of age and older. Removes a provision requiring the Department to cover immunosuppressive drugs and related services associated with post kidney transplant management for noncitizens. Removes provisions concerning the adoption of emergency rules and other matters regarding medical coverage or services for noncitizens.
9	9	LRB104 07779 KTG 17824 b LRB104 07779 KTG 17824 b
10	10	LRB104 07779 KTG 17824 b
11	11	A BILL FOR
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14	14	1 AN ACT concerning public aid.
15	15	2 Be it enacted by the People of the State of Illinois,
16	16	3 represented in the General Assembly:
17	17	4 (5 ILCS 100/5-45.37 rep.)
18	18	5 Section 5. The Illinois Administrative Procedure Act is
19	19	6 amended by repealing Section 5-45.37.
20	20	7 Section 10. The Illinois Public Aid Code is amended by
21	21	8 changing Sections 5-2, 5-5, and 12-4.35 as follows:
22	22	9 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
23	23	10 Sec. 5-2. Classes of persons eligible. Medical assistance
24	24	11 under this Article shall be available to any of the following
25	25	12 classes of persons in respect to whom a plan for coverage has
26	26	13 been submitted to the Governor by the Illinois Department and
27	27	14 approved by him. If changes made in this Section 5-2 require
28	28	15 federal approval, they shall not take effect until such
29	29	16 approval has been received:
30	30	17 1. Recipients of basic maintenance grants under
31	31	18 Articles III and IV.
32	32	19 2. Beginning January 1, 2014, persons otherwise
33	33	20 eligible for basic maintenance under Article III,
34	34	21 excluding any eligibility requirements that are
35	35	22 inconsistent with any federal law or federal regulation,
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39	39	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1456 Introduced , by Rep. Christopher "C.D." Davidsmeyer SYNOPSIS AS INTRODUCED:
40	40	5 ILCS 100/5-45.37 rep.305 ILCS 5/5-2 from Ch. 23, par. 5-2305 ILCS 5/5-5305 ILCS 5/12-4.35 5 ILCS 100/5-45.37 rep. 305 ILCS 5/5-2 from Ch. 23, par. 5-2 305 ILCS 5/5-5 305 ILCS 5/12-4.35
41	41	5 ILCS 100/5-45.37 rep.
42	42	305 ILCS 5/5-2 from Ch. 23, par. 5-2
43	43	305 ILCS 5/5-5
44	44	305 ILCS 5/12-4.35
45	45	Amends the Medical Assistance Article and the Administration Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to cover kidney transplantation services for noncitizens under the medical assistance program. Removes provisions permitting the Department to provide medical services to noncitizens 42 years of age and older. Removes a provision requiring the Department to cover immunosuppressive drugs and related services associated with post kidney transplant management for noncitizens. Removes provisions concerning the adoption of emergency rules and other matters regarding medical coverage or services for noncitizens.
46	46	LRB104 07779 KTG 17824 b LRB104 07779 KTG 17824 b
47	47	LRB104 07779 KTG 17824 b
48	48	A BILL FOR
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54	54	5 ILCS 100/5-45.37 rep.
55	55	305 ILCS 5/5-2 from Ch. 23, par. 5-2
56	56	305 ILCS 5/5-5
57	57	305 ILCS 5/12-4.35
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76	76	1 as interpreted by the U.S. Department of Health and Human
77	77	2 Services, but who fail to qualify thereunder on the basis
78	78	3 of need, and who have insufficient income and resources to
79	79	4 meet the costs of necessary medical care, including, but
80	80	5 not limited to, the following:
81	81	6 (a) All persons otherwise eligible for basic
82	82	7 maintenance under Article III but who fail to qualify
83	83	8 under that Article on the basis of need and who meet
84	84	9 either of the following requirements:
85	85	10 (i) their income, as determined by the
86	86	11 Illinois Department in accordance with any federal
87	87	12 requirements, is equal to or less than 100% of the
88	88	13 federal poverty level; or
89	89	14 (ii) their income, after the deduction of
90	90	15 costs incurred for medical care and for other
91	91	16 types of remedial care, is equal to or less than
92	92	17 100% of the federal poverty level.
93	93	18 (b) (Blank).
94	94	19 3. (Blank).
95	95	20 4. Persons not eligible under any of the preceding
96	96	21 paragraphs who fall sick, are injured, or die, not having
97	97	22 sufficient money, property or other resources to meet the
98	98	23 costs of necessary medical care or funeral and burial
99	99	24 expenses.
100	100	25 5.(a) Beginning January 1, 2020, individuals during
101	101	26 pregnancy and during the 12-month period beginning on the
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112	112	1 last day of the pregnancy, together with their infants,
113	113	2 whose income is at or below 200% of the federal poverty
114	114	3 level. Until September 30, 2019, or sooner if the
115	115	4 maintenance of effort requirements under the Patient
116	116	5 Protection and Affordable Care Act are eliminated or may
117	117	6 be waived before then, individuals during pregnancy and
118	118	7 during the 12-month period beginning on the last day of
119	119	8 the pregnancy, whose countable monthly income, after the
120	120	9 deduction of costs incurred for medical care and for other
121	121	10 types of remedial care as specified in administrative
122	122	11 rule, is equal to or less than the Medical Assistance-No
123	123	12 Grant(C) (MANG(C)) Income Standard in effect on April 1,
124	124	13 2013 as set forth in administrative rule.
125	125	14 (b) The plan for coverage shall provide ambulatory
126	126	15 prenatal care to pregnant individuals during a presumptive
127	127	16 eligibility period and establish an income eligibility
128	128	17 standard that is equal to 200% of the federal poverty
129	129	18 level, provided that costs incurred for medical care are
130	130	19 not taken into account in determining such income
131	131	20 eligibility.
132	132	21 (c) The Illinois Department may conduct a
133	133	22 demonstration in at least one county that will provide
134	134	23 medical assistance to pregnant individuals together with
135	135	24 their infants and children up to one year of age, where the
136	136	25 income eligibility standard is set up to 185% of the
137	137	26 nonfarm income official poverty line, as defined by the
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148	148	1 federal Office of Management and Budget. The Illinois
149	149	2 Department shall seek and obtain necessary authorization
150	150	3 provided under federal law to implement such a
151	151	4 demonstration. Such demonstration may establish resource
152	152	5 standards that are not more restrictive than those
153	153	6 established under Article IV of this Code.
154	154	7 6. (a) Subject to federal approval, children younger
155	155	8 than age 19 when countable income is at or below 313% of
156	156	9 the federal poverty level, as determined by the Department
157	157	10 and in accordance with all applicable federal
158	158	11 requirements. The Department is authorized to adopt
159	159	12 emergency rules to implement the changes made to this
160	160	13 paragraph by Public Act 102-43. Until September 30, 2019,
161	161	14 or sooner if the maintenance of effort requirements under
162	162	15 the Patient Protection and Affordable Care Act are
163	163	16 eliminated or may be waived before then, children younger
164	164	17 than age 19 whose countable monthly income, after the
165	165	18 deduction of costs incurred for medical care and for other
166	166	19 types of remedial care as specified in administrative
167	167	20 rule, is equal to or less than the Medical Assistance-No
168	168	21 Grant(C) (MANG(C)) Income Standard in effect on April 1,
169	169	22 2013 as set forth in administrative rule.
170	170	23 (b) Children and youth who are under temporary custody
171	171	24 or guardianship of the Department of Children and Family
172	172	25 Services or who receive financial assistance in support of
173	173	26 an adoption or guardianship placement from the Department
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184	184	1 of Children and Family Services.
185	185	2 7. (Blank).
186	186	3 8. As required under federal law, persons who are
187	187	4 eligible for Transitional Medical Assistance as a result
188	188	5 of an increase in earnings or child or spousal support
189	189	6 received. The plan for coverage for this class of persons
190	190	7 shall:
191	191	8 (a) extend the medical assistance coverage to the
192	192	9 extent required by federal law; and
193	193	10 (b) offer persons who have initially received 6
194	194	11 months of the coverage provided in paragraph (a)
195	195	12 above, the option of receiving an additional 6 months
196	196	13 of coverage, subject to the following:
197	197	14 (i) such coverage shall be pursuant to
198	198	15 provisions of the federal Social Security Act;
199	199	16 (ii) such coverage shall include all services
200	200	17 covered under Illinois' State Medicaid Plan;
201	201	18 (iii) no premium shall be charged for such
202	202	19 coverage; and
203	203	20 (iv) such coverage shall be suspended in the
204	204	21 event of a person's failure without good cause to
205	205	22 file in a timely fashion reports required for this
206	206	23 coverage under the Social Security Act and
207	207	24 coverage shall be reinstated upon the filing of
208	208	25 such reports if the person remains otherwise
209	209	26 eligible.
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220	220	1 9. Persons with acquired immunodeficiency syndrome
221	221	2 (AIDS) or with AIDS-related conditions with respect to
222	222	3 whom there has been a determination that but for home or
223	223	4 community-based services such individuals would require
224	224	5 the level of care provided in an inpatient hospital,
225	225	6 skilled nursing facility or intermediate care facility the
226	226	7 cost of which is reimbursed under this Article. Assistance
227	227	8 shall be provided to such persons to the maximum extent
228	228	9 permitted under Title XIX of the Federal Social Security
229	229	10 Act.
230	230	11 10. Participants in the long-term care insurance
231	231	12 partnership program established under the Illinois
232	232	13 Long-Term Care Partnership Program Act who meet the
233	233	14 qualifications for protection of resources described in
234	234	15 Section 15 of that Act.
235	235	16 11. Persons with disabilities who are employed and
236	236	17 eligible for Medicaid, pursuant to Section
237	237	18 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
238	238	19 subject to federal approval, persons with a medically
239	239	20 improved disability who are employed and eligible for
240	240	21 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
241	241	22 the Social Security Act, as provided by the Illinois
242	242	23 Department by rule. In establishing eligibility standards
243	243	24 under this paragraph 11, the Department shall, subject to
244	244	25 federal approval:
245	245	26 (a) set the income eligibility standard at not
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256	256	1 lower than 350% of the federal poverty level;
257	257	2 (b) exempt retirement accounts that the person
258	258	3 cannot access without penalty before the age of 59
259	259	4 1/2, and medical savings accounts established pursuant
260	260	5 to 26 U.S.C. 220;
261	261	6 (c) allow non-exempt assets up to $25,000 as to
262	262	7 those assets accumulated during periods of eligibility
263	263	8 under this paragraph 11; and
264	264	9 (d) continue to apply subparagraphs (b) and (c) in
265	265	10 determining the eligibility of the person under this
266	266	11 Article even if the person loses eligibility under
267	267	12 this paragraph 11.
268	268	13 12. Subject to federal approval, persons who are
269	269	14 eligible for medical assistance coverage under applicable
270	270	15 provisions of the federal Social Security Act and the
271	271	16 federal Breast and Cervical Cancer Prevention and
272	272	17 Treatment Act of 2000. Those eligible persons are defined
273	273	18 to include, but not be limited to, the following persons:
274	274	19 (1) persons who have been screened for breast or
275	275	20 cervical cancer under the U.S. Centers for Disease
276	276	21 Control and Prevention Breast and Cervical Cancer
277	277	22 Program established under Title XV of the federal
278	278	23 Public Health Service Act in accordance with the
279	279	24 requirements of Section 1504 of that Act as
280	280	25 administered by the Illinois Department of Public
281	281	26 Health; and
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292	292	1 (2) persons whose screenings under the above
293	293	2 program were funded in whole or in part by funds
294	294	3 appropriated to the Illinois Department of Public
295	295	4 Health for breast or cervical cancer screening.
296	296	5 "Medical assistance" under this paragraph 12 shall be
297	297	6 identical to the benefits provided under the State's
298	298	7 approved plan under Title XIX of the Social Security Act.
299	299	8 The Department must request federal approval of the
300	300	9 coverage under this paragraph 12 within 30 days after July
301	301	10 3, 2001 (the effective date of Public Act 92-47).
302	302	11 In addition to the persons who are eligible for
303	303	12 medical assistance pursuant to subparagraphs (1) and (2)
304	304	13 of this paragraph 12, and to be paid from funds
305	305	14 appropriated to the Department for its medical programs,
306	306	15 any uninsured person as defined by the Department in rules
307	307	16 residing in Illinois who is younger than 65 years of age,
308	308	17 who has been screened for breast and cervical cancer in
309	309	18 accordance with standards and procedures adopted by the
310	310	19 Department of Public Health for screening, and who is
311	311	20 referred to the Department by the Department of Public
312	312	21 Health as being in need of treatment for breast or
313	313	22 cervical cancer is eligible for medical assistance
314	314	23 benefits that are consistent with the benefits provided to
315	315	24 those persons described in subparagraphs (1) and (2).
316	316	25 Medical assistance coverage for the persons who are
317	317	26 eligible under the preceding sentence is not dependent on
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328	328	1 federal approval, but federal moneys may be used to pay
329	329	2 for services provided under that coverage upon federal
330	330	3 approval.
331	331	4 13. Subject to appropriation and to federal approval,
332	332	5 persons living with HIV/AIDS who are not otherwise
333	333	6 eligible under this Article and who qualify for services
334	334	7 covered under Section 5-5.04 as provided by the Illinois
335	335	8 Department by rule.
336	336	9 14. Subject to the availability of funds for this
337	337	10 purpose, the Department may provide coverage under this
338	338	11 Article to persons who reside in Illinois who are not
339	339	12 eligible under any of the preceding paragraphs and who
340	340	13 meet the income guidelines of paragraph 2(a) of this
341	341	14 Section and (i) have an application for asylum pending
342	342	15 before the federal Department of Homeland Security or on
343	343	16 appeal before a court of competent jurisdiction and are
344	344	17 represented either by counsel or by an advocate accredited
345	345	18 by the federal Department of Homeland Security and
346	346	19 employed by a not-for-profit organization in regard to
347	347	20 that application or appeal, or (ii) are receiving services
348	348	21 through a federally funded torture treatment center.
349	349	22 Medical coverage under this paragraph 14 may be provided
350	350	23 for up to 24 continuous months from the initial
351	351	24 eligibility date so long as an individual continues to
352	352	25 satisfy the criteria of this paragraph 14. If an
353	353	26 individual has an appeal pending regarding an application
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364	364	1 for asylum before the Department of Homeland Security,
365	365	2 eligibility under this paragraph 14 may be extended until
366	366	3 a final decision is rendered on the appeal. The Department
367	367	4 may adopt rules governing the implementation of this
368	368	5 paragraph 14.
369	369	6 15. Family Care Eligibility.
370	370	7 (a) On and after July 1, 2012, a parent or other
371	371	8 caretaker relative who is 19 years of age or older when
372	372	9 countable income is at or below 133% of the federal
373	373	10 poverty level. A person may not spend down to become
374	374	11 eligible under this paragraph 15.
375	375	12 (b) Eligibility shall be reviewed annually.
376	376	13 (c) (Blank).
377	377	14 (d) (Blank).
378	378	15 (e) (Blank).
379	379	16 (f) (Blank).
380	380	17 (g) (Blank).
381	381	18 (h) (Blank).
382	382	19 (i) Following termination of an individual's
383	383	20 coverage under this paragraph 15, the individual must
384	384	21 be determined eligible before the person can be
385	385	22 re-enrolled.
386	386	23 16. Subject to appropriation, uninsured persons who
387	387	24 are not otherwise eligible under this Section who have
388	388	25 been certified and referred by the Department of Public
389	389	26 Health as having been screened and found to need
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400	400	1 diagnostic evaluation or treatment, or both diagnostic
401	401	2 evaluation and treatment, for prostate or testicular
402	402	3 cancer. For the purposes of this paragraph 16, uninsured
403	403	4 persons are those who do not have creditable coverage, as
404	404	5 defined under the Health Insurance Portability and
405	405	6 Accountability Act, or have otherwise exhausted any
406	406	7 insurance benefits they may have had, for prostate or
407	407	8 testicular cancer diagnostic evaluation or treatment, or
408	408	9 both diagnostic evaluation and treatment. To be eligible,
409	409	10 a person must furnish a Social Security number. A person's
410	410	11 assets are exempt from consideration in determining
411	411	12 eligibility under this paragraph 16. Such persons shall be
412	412	13 eligible for medical assistance under this paragraph 16
413	413	14 for so long as they need treatment for the cancer. A person
414	414	15 shall be considered to need treatment if, in the opinion
415	415	16 of the person's treating physician, the person requires
416	416	17 therapy directed toward cure or palliation of prostate or
417	417	18 testicular cancer, including recurrent metastatic cancer
418	418	19 that is a known or presumed complication of prostate or
419	419	20 testicular cancer and complications resulting from the
420	420	21 treatment modalities themselves. Persons who require only
421	421	22 routine monitoring services are not considered to need
422	422	23 treatment. "Medical assistance" under this paragraph 16
423	423	24 shall be identical to the benefits provided under the
424	424	25 State's approved plan under Title XIX of the Social
425	425	26 Security Act. Notwithstanding any other provision of law,
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436	436	1 the Department (i) does not have a claim against the
437	437	2 estate of a deceased recipient of services under this
438	438	3 paragraph 16 and (ii) does not have a lien against any
439	439	4 homestead property or other legal or equitable real
440	440	5 property interest owned by a recipient of services under
441	441	6 this paragraph 16.
442	442	7 17. Persons who, pursuant to a waiver approved by the
443	443	8 Secretary of the U.S. Department of Health and Human
444	444	9 Services, are eligible for medical assistance under Title
445	445	10 XIX or XXI of the federal Social Security Act.
446	446	11 Notwithstanding any other provision of this Code and
447	447	12 consistent with the terms of the approved waiver, the
448	448	13 Illinois Department, may by rule:
449	449	14 (a) Limit the geographic areas in which the waiver
450	450	15 program operates.
451	451	16 (b) Determine the scope, quantity, duration, and
452	452	17 quality, and the rate and method of reimbursement, of
453	453	18 the medical services to be provided, which may differ
454	454	19 from those for other classes of persons eligible for
455	455	20 assistance under this Article.
456	456	21 (c) Restrict the persons' freedom in choice of
457	457	22 providers.
458	458	23 18. Beginning January 1, 2014, persons aged 19 or
459	459	24 older, but younger than 65, who are not otherwise eligible
460	460	25 for medical assistance under this Section 5-2, who qualify
461	461	26 for medical assistance pursuant to 42 U.S.C.
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472	472	1 1396a(a)(10)(A)(i)(VIII) and applicable federal
473	473	2 regulations, and who have income at or below 133% of the
474	474	3 federal poverty level plus 5% for the applicable family
475	475	4 size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
476	476	5 applicable federal regulations. Persons eligible for
477	477	6 medical assistance under this paragraph 18 shall receive
478	478	7 coverage for the Health Benefits Service Package as that
479	479	8 term is defined in subsection (m) of Section 5-1.1 of this
480	480	9 Code. If Illinois' federal medical assistance percentage
481	481	10 (FMAP) is reduced below 90% for persons eligible for
482	482	11 medical assistance under this paragraph 18, eligibility
483	483	12 under this paragraph 18 shall cease no later than the end
484	484	13 of the third month following the month in which the
485	485	14 reduction in FMAP takes effect.
486	486	15 19. Beginning January 1, 2014, as required under 42
487	487	16 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
488	488	17 and younger than age 26 who are not otherwise eligible for
489	489	18 medical assistance under paragraphs (1) through (17) of
490	490	19 this Section who (i) were in foster care under the
491	491	20 responsibility of the State on the date of attaining age
492	492	21 18 or on the date of attaining age 21 when a court has
493	493	22 continued wardship for good cause as provided in Section
494	494	23 2-31 of the Juvenile Court Act of 1987 and (ii) received
495	495	24 medical assistance under the Illinois Title XIX State Plan
496	496	25 or waiver of such plan while in foster care.
497	497	26 20. Beginning January 1, 2018, persons who are
498	498
499	499
500	500
501	501
502	502
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508	508	1 foreign-born victims of human trafficking, torture, or
509	509	2 other serious crimes as defined in Section 2-19 of this
510	510	3 Code and their derivative family members if such persons:
511	511	4 (i) reside in Illinois; (ii) are not eligible under any of
512	512	5 the preceding paragraphs; (iii) meet the income guidelines
513	513	6 of subparagraph (a) of paragraph 2; and (iv) meet the
514	514	7 nonfinancial eligibility requirements of Sections 16-2,
515	515	8 16-3, and 16-5 of this Code. The Department may extend
516	516	9 medical assistance for persons who are foreign-born
517	517	10 victims of human trafficking, torture, or other serious
518	518	11 crimes whose medical assistance would be terminated
519	519	12 pursuant to subsection (b) of Section 16-5 if the
520	520	13 Department determines that the person, during the year of
521	521	14 initial eligibility (1) experienced a health crisis, (2)
522	522	15 has been unable, after reasonable attempts, to obtain
523	523	16 necessary information from a third party, or (3) has other
524	524	17 extenuating circumstances that prevented the person from
525	525	18 completing his or her application for status. The
526	526	19 Department may adopt any rules necessary to implement the
527	527	20 provisions of this paragraph.
528	528	21 21. (Blank). Persons who are not otherwise eligible
529	529	22 for medical assistance under this Section who may qualify
530	530	23 for medical assistance pursuant to 42 U.S.C.
531	531	24 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
532	532	25 duration of any federal or State declared emergency due to
533	533	26 COVID-19. Medical assistance to persons eligible for
534	534
535	535
536	536
537	537
538	538
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540	540
541	541
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544	544	1 medical assistance solely pursuant to this paragraph 21
545	545	2 shall be limited to any in vitro diagnostic product (and
546	546	3 the administration of such product) described in 42 U.S.C.
547	547	4 1396d(a)(3)(B) on or after March 18, 2020, any visit
548	548	5 described in 42 U.S.C. 1396o(a)(2)(G), or any other
549	549	6 medical assistance that may be federally authorized for
550	550	7 this class of persons. The Department may also cover
551	551	8 treatment of COVID-19 for this class of persons, or any
552	552	9 similar category of uninsured individuals, to the extent
553	553	10 authorized under a federally approved 1115 Waiver or other
554	554	11 federal authority. Notwithstanding the provisions of
555	555	12 Section 1-11 of this Code, due to the nature of the
556	556	13 COVID-19 public health emergency, the Department may cover
557	557	14 and provide the medical assistance described in this
558	558	15 paragraph 21 to noncitizens who would otherwise meet the
559	559	16 eligibility requirements for the class of persons
560	560	17 described in this paragraph 21 for the duration of the
561	561	18 State emergency period.
562	562	19 In implementing the provisions of Public Act 96-20, the
563	563	20 Department is authorized to adopt only those rules necessary,
564	564	21 including emergency rules. Nothing in Public Act 96-20 permits
565	565	22 the Department to adopt rules or issue a decision that expands
566	566	23 eligibility for the FamilyCare Program to a person whose
567	567	24 income exceeds 185% of the Federal Poverty Level as determined
568	568	25 from time to time by the U.S. Department of Health and Human
569	569	26 Services, unless the Department is provided with express
570	570
571	571
572	572
573	573
574	574
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580	580	1 statutory authority.
581	581	2 The eligibility of any such person for medical assistance
582	582	3 under this Article is not affected by the payment of any grant
583	583	4 under the Senior Citizens and Persons with Disabilities
584	584	5 Property Tax Relief Act or any distributions or items of
585	585	6 income described under subparagraph (X) of paragraph (2) of
586	586	7 subsection (a) of Section 203 of the Illinois Income Tax Act.
587	587	8 The Department shall by rule establish the amounts of
588	588	9 assets to be disregarded in determining eligibility for
589	589	10 medical assistance, which shall at a minimum equal the amounts
590	590	11 to be disregarded under the Federal Supplemental Security
591	591	12 Income Program. The amount of assets of a single person to be
592	592	13 disregarded shall not be less than $2,000, and the amount of
593	593	14 assets of a married couple to be disregarded shall not be less
594	594	15 than $3,000.
595	595	16 To the extent permitted under federal law, any person
596	596	17 found guilty of a second violation of Article VIIIA shall be
597	597	18 ineligible for medical assistance under this Article, as
598	598	19 provided in Section 8A-8.
599	599	20 The eligibility of any person for medical assistance under
600	600	21 this Article shall not be affected by the receipt by the person
601	601	22 of donations or benefits from fundraisers held for the person
602	602	23 in cases of serious illness, as long as neither the person nor
603	603	24 members of the person's family have actual control over the
604	604	25 donations or benefits or the disbursement of the donations or
605	605	26 benefits.
606	606
607	607
608	608
609	609
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612	612
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616	616	1 Notwithstanding any other provision of this Code, if the
617	617	2 United States Supreme Court holds Title II, Subtitle A,
618	618	3 Section 2001(a) of Public Law 111-148 to be unconstitutional,
619	619	4 or if a holding of Public Law 111-148 makes Medicaid
620	620	5 eligibility allowed under Section 2001(a) inoperable, the
621	621	6 State or a unit of local government shall be prohibited from
622	622	7 enrolling individuals in the Medical Assistance Program as the
623	623	8 result of federal approval of a State Medicaid waiver on or
624	624	9 after June 14, 2012 (the effective date of Public Act 97-687),
625	625	10 and any individuals enrolled in the Medical Assistance Program
626	626	11 pursuant to eligibility permitted as a result of such a State
627	627	12 Medicaid waiver shall become immediately ineligible.
628	628	13 Notwithstanding any other provision of this Code, if an
629	629	14 Act of Congress that becomes a Public Law eliminates Section
630	630	15 2001(a) of Public Law 111-148, the State or a unit of local
631	631	16 government shall be prohibited from enrolling individuals in
632	632	17 the Medical Assistance Program as the result of federal
633	633	18 approval of a State Medicaid waiver on or after June 14, 2012
634	634	19 (the effective date of Public Act 97-687), and any individuals
635	635	20 enrolled in the Medical Assistance Program pursuant to
636	636	21 eligibility permitted as a result of such a State Medicaid
637	637	22 waiver shall become immediately ineligible.
638	638	23 Effective October 1, 2013, the determination of
639	639	24 eligibility of persons who qualify under paragraphs 5, 6, 8,
640	640	25 15, 17, and 18 of this Section shall comply with the
641	641	26 requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
642	642
643	643
644	644
645	645
646	646
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648	648
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652	652	1 regulations.
653	653	2 The Department of Healthcare and Family Services, the
654	654	3 Department of Human Services, and the Illinois health
655	655	4 insurance marketplace shall work cooperatively to assist
656	656	5 persons who would otherwise lose health benefits as a result
657	657	6 of changes made under Public Act 98-104 to transition to other
658	658	7 health insurance coverage.
659	659	8 (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
660	660	9 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff.
661	661	10 10-8-21; 102-813, eff. 5-13-22.)
662	662	11 (305 ILCS 5/5-5)
663	663	12 (Text of Section before amendment by P.A. 103-808)
664	664	13 Sec. 5-5. Medical services. The Illinois Department, by
665	665	14 rule, shall determine the quantity and quality of and the rate
666	666	15 of reimbursement for the medical assistance for which payment
667	667	16 will be authorized, and the medical services to be provided,
668	668	17 which may include all or part of the following: (1) inpatient
669	669	18 hospital services; (2) outpatient hospital services; (3) other
670	670	19 laboratory and X-ray services; (4) skilled nursing home
671	671	20 services; (5) physicians' services whether furnished in the
672	672	21 office, the patient's home, a hospital, a skilled nursing
673	673	22 home, or elsewhere; (6) medical care, or any other type of
674	674	23 remedial care furnished by licensed practitioners; (7) home
675	675	24 health care services; (8) private duty nursing service; (9)
676	676	25 clinic services; (10) dental services, including prevention
677	677
678	678
679	679
680	680
681	681
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683	683
684	684
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686	686	HB1456 - 19 - LRB104 07779 KTG 17824 b
687	687	1 and treatment of periodontal disease and dental caries disease
688	688	2 for pregnant individuals, provided by an individual licensed
689	689	3 to practice dentistry or dental surgery; for purposes of this
690	690	4 item (10), "dental services" means diagnostic, preventive, or
691	691	5 corrective procedures provided by or under the supervision of
692	692	6 a dentist in the practice of his or her profession; (11)
693	693	7 physical therapy and related services; (12) prescribed drugs,
694	694	8 dentures, and prosthetic devices; and eyeglasses prescribed by
695	695	9 a physician skilled in the diseases of the eye, or by an
696	696	10 optometrist, whichever the person may select; (13) other
697	697	11 diagnostic, screening, preventive, and rehabilitative
698	698	12 services, including to ensure that the individual's need for
699	699	13 intervention or treatment of mental disorders or substance use
700	700	14 disorders or co-occurring mental health and substance use
701	701	15 disorders is determined using a uniform screening, assessment,
702	702	16 and evaluation process inclusive of criteria, for children and
703	703	17 adults; for purposes of this item (13), a uniform screening,
704	704	18 assessment, and evaluation process refers to a process that
705	705	19 includes an appropriate evaluation and, as warranted, a
706	706	20 referral; "uniform" does not mean the use of a singular
707	707	21 instrument, tool, or process that all must utilize; (14)
708	708	22 transportation and such other expenses as may be necessary;
709	709	23 (15) medical treatment of sexual assault survivors, as defined
710	710	24 in Section 1a of the Sexual Assault Survivors Emergency
711	711	25 Treatment Act, for injuries sustained as a result of the
712	712	26 sexual assault, including examinations and laboratory tests to
713	713
714	714
715	715
716	716
717	717
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719	719
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723	723	1 discover evidence which may be used in criminal proceedings
724	724	2 arising from the sexual assault; (16) the diagnosis and
725	725	3 treatment of sickle cell anemia; (16.5) services performed by
726	726	4 a chiropractic physician licensed under the Medical Practice
727	727	5 Act of 1987 and acting within the scope of his or her license,
728	728	6 including, but not limited to, chiropractic manipulative
729	729	7 treatment; and (17) any other medical care, and any other type
730	730	8 of remedial care recognized under the laws of this State. The
731	731	9 term "any other type of remedial care" shall include nursing
732	732	10 care and nursing home service for persons who rely on
733	733	11 treatment by spiritual means alone through prayer for healing.
734	734	12 Notwithstanding any other provision of this Section, a
735	735	13 comprehensive tobacco use cessation program that includes
736	736	14 purchasing prescription drugs or prescription medical devices
737	737	15 approved by the Food and Drug Administration shall be covered
738	738	16 under the medical assistance program under this Article for
739	739	17 persons who are otherwise eligible for assistance under this
740	740	18 Article.
741	741	19 Notwithstanding any other provision of this Code,
742	742	20 reproductive health care that is otherwise legal in Illinois
743	743	21 shall be covered under the medical assistance program for
744	744	22 persons who are otherwise eligible for medical assistance
745	745	23 under this Article.
746	746	24 Notwithstanding any other provision of this Section, all
747	747	25 tobacco cessation medications approved by the United States
748	748	26 Food and Drug Administration and all individual and group
749	749
750	750
751	751
752	752
753	753
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755	755
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759	759	1 tobacco cessation counseling services and telephone-based
760	760	2 counseling services and tobacco cessation medications provided
761	761	3 through the Illinois Tobacco Quitline shall be covered under
762	762	4 the medical assistance program for persons who are otherwise
763	763	5 eligible for assistance under this Article. The Department
764	764	6 shall comply with all federal requirements necessary to obtain
765	765	7 federal financial participation, as specified in 42 CFR
766	766	8 433.15(b)(7), for telephone-based counseling services provided
767	767	9 through the Illinois Tobacco Quitline, including, but not
768	768	10 limited to: (i) entering into a memorandum of understanding or
769	769	11 interagency agreement with the Department of Public Health, as
770	770	12 administrator of the Illinois Tobacco Quitline; and (ii)
771	771	13 developing a cost allocation plan for Medicaid-allowable
772	772	14 Illinois Tobacco Quitline services in accordance with 45 CFR
773	773	15 95.507. The Department shall submit the memorandum of
774	774	16 understanding or interagency agreement, the cost allocation
775	775	17 plan, and all other necessary documentation to the Centers for
776	776	18 Medicare and Medicaid Services for review and approval.
777	777	19 Coverage under this paragraph shall be contingent upon federal
778	778	20 approval.
779	779	21 Notwithstanding any other provision of this Code, the
780	780	22 Illinois Department may not require, as a condition of payment
781	781	23 for any laboratory test authorized under this Article, that a
782	782	24 physician's handwritten signature appear on the laboratory
783	783	25 test order form. The Illinois Department may, however, impose
784	784	26 other appropriate requirements regarding laboratory test order
785	785
786	786
787	787
788	788
789	789
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791	791
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795	795	1 documentation.
796	796	2 Upon receipt of federal approval of an amendment to the
797	797	3 Illinois Title XIX State Plan for this purpose, the Department
798	798	4 shall authorize the Chicago Public Schools (CPS) to procure a
799	799	5 vendor or vendors to manufacture eyeglasses for individuals
800	800	6 enrolled in a school within the CPS system. CPS shall ensure
801	801	7 that its vendor or vendors are enrolled as providers in the
802	802	8 medical assistance program and in any capitated Medicaid
803	803	9 managed care entity (MCE) serving individuals enrolled in a
804	804	10 school within the CPS system. Under any contract procured
805	805	11 under this provision, the vendor or vendors must serve only
806	806	12 individuals enrolled in a school within the CPS system. Claims
807	807	13 for services provided by CPS's vendor or vendors to recipients
808	808	14 of benefits in the medical assistance program under this Code,
809	809	15 the Children's Health Insurance Program, or the Covering ALL
810	810	16 KIDS Health Insurance Program shall be submitted to the
811	811	17 Department or the MCE in which the individual is enrolled for
812	812	18 payment and shall be reimbursed at the Department's or the
813	813	19 MCE's established rates or rate methodologies for eyeglasses.
814	814	20 On and after July 1, 2012, the Department of Healthcare
815	815	21 and Family Services may provide the following services to
816	816	22 persons eligible for assistance under this Article who are
817	817	23 participating in education, training or employment programs
818	818	24 operated by the Department of Human Services as successor to
819	819	25 the Department of Public Aid:
820	820	26 (1) dental services provided by or under the
821	821
822	822
823	823
824	824
825	825
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827	827
828	828
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831	831	1 supervision of a dentist; and
832	832	2 (2) eyeglasses prescribed by a physician skilled in
833	833	3 the diseases of the eye, or by an optometrist, whichever
834	834	4 the person may select.
835	835	5 On and after July 1, 2018, the Department of Healthcare
836	836	6 and Family Services shall provide dental services to any adult
837	837	7 who is otherwise eligible for assistance under the medical
838	838	8 assistance program. As used in this paragraph, "dental
839	839	9 services" means diagnostic, preventative, restorative, or
840	840	10 corrective procedures, including procedures and services for
841	841	11 the prevention and treatment of periodontal disease and dental
842	842	12 caries disease, provided by an individual who is licensed to
843	843	13 practice dentistry or dental surgery or who is under the
844	844	14 supervision of a dentist in the practice of his or her
845	845	15 profession.
846	846	16 On and after July 1, 2018, targeted dental services, as
847	847	17 set forth in Exhibit D of the Consent Decree entered by the
848	848	18 United States District Court for the Northern District of
849	849	19 Illinois, Eastern Division, in the matter of Memisovski v.
850	850	20 Maram, Case No. 92 C 1982, that are provided to adults under
851	851	21 the medical assistance program shall be established at no less
852	852	22 than the rates set forth in the "New Rate" column in Exhibit D
853	853	23 of the Consent Decree for targeted dental services that are
854	854	24 provided to persons under the age of 18 under the medical
855	855	25 assistance program.
856	856	26 Subject to federal approval, on and after January 1, 2025,
857	857
858	858
859	859
860	860
861	861
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867	867	1 the rates paid for sedation evaluation and the provision of
868	868	2 deep sedation and intravenous sedation for the purpose of
869	869	3 dental services shall be increased by 33% above the rates in
870	870	4 effect on December 31, 2024. The rates paid for nitrous oxide
871	871	5 sedation shall not be impacted by this paragraph and shall
872	872	6 remain the same as the rates in effect on December 31, 2024.
873	873	7 Notwithstanding any other provision of this Code and
874	874	8 subject to federal approval, the Department may adopt rules to
875	875	9 allow a dentist who is volunteering his or her service at no
876	876	10 cost to render dental services through an enrolled
877	877	11 not-for-profit health clinic without the dentist personally
878	878	12 enrolling as a participating provider in the medical
879	879	13 assistance program. A not-for-profit health clinic shall
880	880	14 include a public health clinic or Federally Qualified Health
881	881	15 Center or other enrolled provider, as determined by the
882	882	16 Department, through which dental services covered under this
883	883	17 Section are performed. The Department shall establish a
884	884	18 process for payment of claims for reimbursement for covered
885	885	19 dental services rendered under this provision.
886	886	20 Subject to appropriation and to federal approval, the
887	887	21 Department shall file administrative rules updating the
888	888	22 Handicapping Labio-Lingual Deviation orthodontic scoring tool
889	889	23 by January 1, 2025, or as soon as practicable.
890	890	24 On and after January 1, 2022, the Department of Healthcare
891	891	25 and Family Services shall administer and regulate a
892	892	26 school-based dental program that allows for the out-of-office
893	893
894	894
895	895
896	896
897	897
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899	899
900	900
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903	903	1 delivery of preventative dental services in a school setting
904	904	2 to children under 19 years of age. The Department shall
905	905	3 establish, by rule, guidelines for participation by providers
906	906	4 and set requirements for follow-up referral care based on the
907	907	5 requirements established in the Dental Office Reference Manual
908	908	6 published by the Department that establishes the requirements
909	909	7 for dentists participating in the All Kids Dental School
910	910	8 Program. Every effort shall be made by the Department when
911	911	9 developing the program requirements to consider the different
912	912	10 geographic differences of both urban and rural areas of the
913	913	11 State for initial treatment and necessary follow-up care. No
914	914	12 provider shall be charged a fee by any unit of local government
915	915	13 to participate in the school-based dental program administered
916	916	14 by the Department. Nothing in this paragraph shall be
917	917	15 construed to limit or preempt a home rule unit's or school
918	918	16 district's authority to establish, change, or administer a
919	919	17 school-based dental program in addition to, or independent of,
920	920	18 the school-based dental program administered by the
921	921	19 Department.
922	922	20 The Illinois Department, by rule, may distinguish and
923	923	21 classify the medical services to be provided only in
924	924	22 accordance with the classes of persons designated in Section
925	925	23 5-2.
926	926	24 The Department of Healthcare and Family Services must
927	927	25 provide coverage and reimbursement for amino acid-based
928	928	26 elemental formulas, regardless of delivery method, for the
929	929
930	930
931	931
932	932
933	933
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935	935
936	936
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938	938	HB1456 - 26 - LRB104 07779 KTG 17824 b
939	939	1 diagnosis and treatment of (i) eosinophilic disorders and (ii)
940	940	2 short bowel syndrome when the prescribing physician has issued
941	941	3 a written order stating that the amino acid-based elemental
942	942	4 formula is medically necessary.
943	943	5 The Illinois Department shall authorize the provision of,
944	944	6 and shall authorize payment for, screening by low-dose
945	945	7 mammography for the presence of occult breast cancer for
946	946	8 individuals 35 years of age or older who are eligible for
947	947	9 medical assistance under this Article, as follows:
948	948	10 (A) A baseline mammogram for individuals 35 to 39
949	949	11 years of age.
950	950	12 (B) An annual mammogram for individuals 40 years of
951	951	13 age or older.
952	952	14 (C) A mammogram at the age and intervals considered
953	953	15 medically necessary by the individual's health care
954	954	16 provider for individuals under 40 years of age and having
955	955	17 a family history of breast cancer, prior personal history
956	956	18 of breast cancer, positive genetic testing, or other risk
957	957	19 factors.
958	958	20 (D) A comprehensive ultrasound screening and MRI of an
959	959	21 entire breast or breasts if a mammogram demonstrates
960	960	22 heterogeneous or dense breast tissue or when medically
961	961	23 necessary as determined by a physician licensed to
962	962	24 practice medicine in all of its branches.
963	963	25 (E) A screening MRI when medically necessary, as
964	964	26 determined by a physician licensed to practice medicine in
965	965
966	966
967	967
968	968
969	969
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971	971
972	972
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975	975	1 all of its branches.
976	976	2 (F) A diagnostic mammogram when medically necessary,
977	977	3 as determined by a physician licensed to practice medicine
978	978	4 in all its branches, advanced practice registered nurse,
979	979	5 or physician assistant.
980	980	6 The Department shall not impose a deductible, coinsurance,
981	981	7 copayment, or any other cost-sharing requirement on the
982	982	8 coverage provided under this paragraph; except that this
983	983	9 sentence does not apply to coverage of diagnostic mammograms
984	984	10 to the extent such coverage would disqualify a high-deductible
985	985	11 health plan from eligibility for a health savings account
986	986	12 pursuant to Section 223 of the Internal Revenue Code (26
987	987	13 U.S.C. 223).
988	988	14 All screenings shall include a physical breast exam,
989	989	15 instruction on self-examination and information regarding the
990	990	16 frequency of self-examination and its value as a preventative
991	991	17 tool.
992	992	18 For purposes of this Section:
993	993	19 "Diagnostic mammogram" means a mammogram obtained using
994	994	20 diagnostic mammography.
995	995	21 "Diagnostic mammography" means a method of screening that
996	996	22 is designed to evaluate an abnormality in a breast, including
997	997	23 an abnormality seen or suspected on a screening mammogram or a
998	998	24 subjective or objective abnormality otherwise detected in the
999	999	25 breast.
1000	1000	26 "Low-dose mammography" means the x-ray examination of the
1001	1001
1002	1002
1003	1003
1004	1004
1005	1005
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1007	1007
1008	1008
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1010	1010	HB1456 - 28 - LRB104 07779 KTG 17824 b
1011	1011	1 breast using equipment dedicated specifically for mammography,
1012	1012	2 including the x-ray tube, filter, compression device, and
1013	1013	3 image receptor, with an average radiation exposure delivery of
1014	1014	4 less than one rad per breast for 2 views of an average size
1015	1015	5 breast. The term also includes digital mammography and
1016	1016	6 includes breast tomosynthesis.
1017	1017	7 "Breast tomosynthesis" means a radiologic procedure that
1018	1018	8 involves the acquisition of projection images over the
1019	1019	9 stationary breast to produce cross-sectional digital
1020	1020	10 three-dimensional images of the breast.
1021	1021	11 If, at any time, the Secretary of the United States
1022	1022	12 Department of Health and Human Services, or its successor
1023	1023	13 agency, promulgates rules or regulations to be published in
1024	1024	14 the Federal Register or publishes a comment in the Federal
1025	1025	15 Register or issues an opinion, guidance, or other action that
1026	1026	16 would require the State, pursuant to any provision of the
1027	1027	17 Patient Protection and Affordable Care Act (Public Law
1028	1028	18 111-148), including, but not limited to, 42 U.S.C.
1029	1029	19 18031(d)(3)(B) or any successor provision, to defray the cost
1030	1030	20 of any coverage for breast tomosynthesis outlined in this
1031	1031	21 paragraph, then the requirement that an insurer cover breast
1032	1032	22 tomosynthesis is inoperative other than any such coverage
1033	1033	23 authorized under Section 1902 of the Social Security Act, 42
1034	1034	24 U.S.C. 1396a, and the State shall not assume any obligation
1035	1035	25 for the cost of coverage for breast tomosynthesis set forth in
1036	1036	26 this paragraph.
1037	1037
1038	1038
1039	1039
1040	1040
1041	1041
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1043	1043
1044	1044
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1046	1046	HB1456 - 29 - LRB104 07779 KTG 17824 b
1047	1047	1 On and after January 1, 2016, the Department shall ensure
1048	1048	2 that all networks of care for adult clients of the Department
1049	1049	3 include access to at least one breast imaging Center of
1050	1050	4 Imaging Excellence as certified by the American College of
1051	1051	5 Radiology.
1052	1052	6 On and after January 1, 2012, providers participating in a
1053	1053	7 quality improvement program approved by the Department shall
1054	1054	8 be reimbursed for screening and diagnostic mammography at the
1055	1055	9 same rate as the Medicare program's rates, including the
1056	1056	10 increased reimbursement for digital mammography and, after
1057	1057	11 January 1, 2023 (the effective date of Public Act 102-1018),
1058	1058	12 breast tomosynthesis.
1059	1059	13 The Department shall convene an expert panel including
1060	1060	14 representatives of hospitals, free-standing mammography
1061	1061	15 facilities, and doctors, including radiologists, to establish
1062	1062	16 quality standards for mammography.
1063	1063	17 On and after January 1, 2017, providers participating in a
1064	1064	18 breast cancer treatment quality improvement program approved
1065	1065	19 by the Department shall be reimbursed for breast cancer
1066	1066	20 treatment at a rate that is no lower than 95% of the Medicare
1067	1067	21 program's rates for the data elements included in the breast
1068	1068	22 cancer treatment quality program.
1069	1069	23 The Department shall convene an expert panel, including
1070	1070	24 representatives of hospitals, free-standing breast cancer
1071	1071	25 treatment centers, breast cancer quality organizations, and
1072	1072	26 doctors, including breast surgeons, reconstructive breast
1073	1073
1074	1074
1075	1075
1076	1076
1077	1077
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1079	1079
1080	1080
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1082	1082	HB1456 - 30 - LRB104 07779 KTG 17824 b
1083	1083	1 surgeons, oncologists, and primary care providers to establish
1084	1084	2 quality standards for breast cancer treatment.
1085	1085	3 Subject to federal approval, the Department shall
1086	1086	4 establish a rate methodology for mammography at federally
1087	1087	5 qualified health centers and other encounter-rate clinics.
1088	1088	6 These clinics or centers may also collaborate with other
1089	1089	7 hospital-based mammography facilities. By January 1, 2016, the
1090	1090	8 Department shall report to the General Assembly on the status
1091	1091	9 of the provision set forth in this paragraph.
1092	1092	10 The Department shall establish a methodology to remind
1093	1093	11 individuals who are age-appropriate for screening mammography,
1094	1094	12 but who have not received a mammogram within the previous 18
1095	1095	13 months, of the importance and benefit of screening
1096	1096	14 mammography. The Department shall work with experts in breast
1097	1097	15 cancer outreach and patient navigation to optimize these
1098	1098	16 reminders and shall establish a methodology for evaluating
1099	1099	17 their effectiveness and modifying the methodology based on the
1100	1100	18 evaluation.
1101	1101	19 The Department shall establish a performance goal for
1102	1102	20 primary care providers with respect to their female patients
1103	1103	21 over age 40 receiving an annual mammogram. This performance
1104	1104	22 goal shall be used to provide additional reimbursement in the
1105	1105	23 form of a quality performance bonus to primary care providers
1106	1106	24 who meet that goal.
1107	1107	25 The Department shall devise a means of case-managing or
1108	1108	26 patient navigation for beneficiaries diagnosed with breast
1109	1109
1110	1110
1111	1111
1112	1112
1113	1113
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1115	1115
1116	1116
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1118	1118	HB1456 - 31 - LRB104 07779 KTG 17824 b
1119	1119	1 cancer. This program shall initially operate as a pilot
1120	1120	2 program in areas of the State with the highest incidence of
1121	1121	3 mortality related to breast cancer. At least one pilot program
1122	1122	4 site shall be in the metropolitan Chicago area and at least one
1123	1123	5 site shall be outside the metropolitan Chicago area. On or
1124	1124	6 after July 1, 2016, the pilot program shall be expanded to
1125	1125	7 include one site in western Illinois, one site in southern
1126	1126	8 Illinois, one site in central Illinois, and 4 sites within
1127	1127	9 metropolitan Chicago. An evaluation of the pilot program shall
1128	1128	10 be carried out measuring health outcomes and cost of care for
1129	1129	11 those served by the pilot program compared to similarly
1130	1130	12 situated patients who are not served by the pilot program.
1131	1131	13 The Department shall require all networks of care to
1132	1132	14 develop a means either internally or by contract with experts
1133	1133	15 in navigation and community outreach to navigate cancer
1134	1134	16 patients to comprehensive care in a timely fashion. The
1135	1135	17 Department shall require all networks of care to include
1136	1136	18 access for patients diagnosed with cancer to at least one
1137	1137	19 academic commission on cancer-accredited cancer program as an
1138	1138	20 in-network covered benefit.
1139	1139	21 The Department shall provide coverage and reimbursement
1140	1140	22 for a human papillomavirus (HPV) vaccine that is approved for
1141	1141	23 marketing by the federal Food and Drug Administration for all
1142	1142	24 persons between the ages of 9 and 45. Subject to federal
1143	1143	25 approval, the Department shall provide coverage and
1144	1144	26 reimbursement for a human papillomavirus (HPV) vaccine for
1145	1145
1146	1146
1147	1147
1148	1148
1149	1149
1150	1150	HB1456 - 31 - LRB104 07779 KTG 17824 b
1151	1151
1152	1152
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1154	1154	HB1456 - 32 - LRB104 07779 KTG 17824 b
1155	1155	1 persons of the age of 46 and above who have been diagnosed with
1156	1156	2 cervical dysplasia with a high risk of recurrence or
1157	1157	3 progression. The Department shall disallow any
1158	1158	4 preauthorization requirements for the administration of the
1159	1159	5 human papillomavirus (HPV) vaccine.
1160	1160	6 On or after July 1, 2022, individuals who are otherwise
1161	1161	7 eligible for medical assistance under this Article shall
1162	1162	8 receive coverage for perinatal depression screenings for the
1163	1163	9 12-month period beginning on the last day of their pregnancy.
1164	1164	10 Medical assistance coverage under this paragraph shall be
1165	1165	11 conditioned on the use of a screening instrument approved by
1166	1166	12 the Department.
1167	1167	13 Any medical or health care provider shall immediately
1168	1168	14 recommend, to any pregnant individual who is being provided
1169	1169	15 prenatal services and is suspected of having a substance use
1170	1170	16 disorder as defined in the Substance Use Disorder Act,
1171	1171	17 referral to a local substance use disorder treatment program
1172	1172	18 licensed by the Department of Human Services or to a licensed
1173	1173	19 hospital which provides substance abuse treatment services.
1174	1174	20 The Department of Healthcare and Family Services shall assure
1175	1175	21 coverage for the cost of treatment of the drug abuse or
1176	1176	22 addiction for pregnant recipients in accordance with the
1177	1177	23 Illinois Medicaid Program in conjunction with the Department
1178	1178	24 of Human Services.
1179	1179	25 All medical providers providing medical assistance to
1180	1180	26 pregnant individuals under this Code shall receive information
1181	1181
1182	1182
1183	1183
1184	1184
1185	1185
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1187	1187
1188	1188
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1190	1190	HB1456 - 33 - LRB104 07779 KTG 17824 b
1191	1191	1 from the Department on the availability of services under any
1192	1192	2 program providing case management services for addicted
1193	1193	3 individuals, including information on appropriate referrals
1194	1194	4 for other social services that may be needed by addicted
1195	1195	5 individuals in addition to treatment for addiction.
1196	1196	6 The Illinois Department, in cooperation with the
1197	1197	7 Departments of Human Services (as successor to the Department
1198	1198	8 of Alcoholism and Substance Abuse) and Public Health, through
1199	1199	9 a public awareness campaign, may provide information
1200	1200	10 concerning treatment for alcoholism and drug abuse and
1201	1201	11 addiction, prenatal health care, and other pertinent programs
1202	1202	12 directed at reducing the number of drug-affected infants born
1203	1203	13 to recipients of medical assistance.
1204	1204	14 Neither the Department of Healthcare and Family Services
1205	1205	15 nor the Department of Human Services shall sanction the
1206	1206	16 recipient solely on the basis of the recipient's substance
1207	1207	17 abuse.
1208	1208	18 The Illinois Department shall establish such regulations
1209	1209	19 governing the dispensing of health services under this Article
1210	1210	20 as it shall deem appropriate. The Department should seek the
1211	1211	21 advice of formal professional advisory committees appointed by
1212	1212	22 the Director of the Illinois Department for the purpose of
1213	1213	23 providing regular advice on policy and administrative matters,
1214	1214	24 information dissemination and educational activities for
1215	1215	25 medical and health care providers, and consistency in
1216	1216	26 procedures to the Illinois Department.
1217	1217
1218	1218
1219	1219
1220	1220
1221	1221
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1223	1223
1224	1224
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1226	1226	HB1456 - 34 - LRB104 07779 KTG 17824 b
1227	1227	1 The Illinois Department may develop and contract with
1228	1228	2 Partnerships of medical providers to arrange medical services
1229	1229	3 for persons eligible under Section 5-2 of this Code.
1230	1230	4 Implementation of this Section may be by demonstration
1231	1231	5 projects in certain geographic areas. The Partnership shall be
1232	1232	6 represented by a sponsor organization. The Department, by
1233	1233	7 rule, shall develop qualifications for sponsors of
1234	1234	8 Partnerships. Nothing in this Section shall be construed to
1235	1235	9 require that the sponsor organization be a medical
1236	1236	10 organization.
1237	1237	11 The sponsor must negotiate formal written contracts with
1238	1238	12 medical providers for physician services, inpatient and
1239	1239	13 outpatient hospital care, home health services, treatment for
1240	1240	14 alcoholism and substance abuse, and other services determined
1241	1241	15 necessary by the Illinois Department by rule for delivery by
1242	1242	16 Partnerships. Physician services must include prenatal and
1243	1243	17 obstetrical care. The Illinois Department shall reimburse
1244	1244	18 medical services delivered by Partnership providers to clients
1245	1245	19 in target areas according to provisions of this Article and
1246	1246	20 the Illinois Health Finance Reform Act, except that:
1247	1247	21 (1) Physicians participating in a Partnership and
1248	1248	22 providing certain services, which shall be determined by
1249	1249	23 the Illinois Department, to persons in areas covered by
1250	1250	24 the Partnership may receive an additional surcharge for
1251	1251	25 such services.
1252	1252	26 (2) The Department may elect to consider and negotiate
1253	1253
1254	1254
1255	1255
1256	1256
1257	1257
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1259	1259
1260	1260
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1263	1263	1 financial incentives to encourage the development of
1264	1264	2 Partnerships and the efficient delivery of medical care.
1265	1265	3 (3) Persons receiving medical services through
1266	1266	4 Partnerships may receive medical and case management
1267	1267	5 services above the level usually offered through the
1268	1268	6 medical assistance program.
1269	1269	7 Medical providers shall be required to meet certain
1270	1270	8 qualifications to participate in Partnerships to ensure the
1271	1271	9 delivery of high quality medical services. These
1272	1272	10 qualifications shall be determined by rule of the Illinois
1273	1273	11 Department and may be higher than qualifications for
1274	1274	12 participation in the medical assistance program. Partnership
1275	1275	13 sponsors may prescribe reasonable additional qualifications
1276	1276	14 for participation by medical providers, only with the prior
1277	1277	15 written approval of the Illinois Department.
1278	1278	16 Nothing in this Section shall limit the free choice of
1279	1279	17 practitioners, hospitals, and other providers of medical
1280	1280	18 services by clients. In order to ensure patient freedom of
1281	1281	19 choice, the Illinois Department shall immediately promulgate
1282	1282	20 all rules and take all other necessary actions so that
1283	1283	21 provided services may be accessed from therapeutically
1284	1284	22 certified optometrists to the full extent of the Illinois
1285	1285	23 Optometric Practice Act of 1987 without discriminating between
1286	1286	24 service providers.
1287	1287	25 The Department shall apply for a waiver from the United
1288	1288	26 States Health Care Financing Administration to allow for the
1289	1289
1290	1290
1291	1291
1292	1292
1293	1293
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1295	1295
1296	1296
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1298	1298	HB1456 - 36 - LRB104 07779 KTG 17824 b
1299	1299	1 implementation of Partnerships under this Section.
1300	1300	2 The Illinois Department shall require health care
1301	1301	3 providers to maintain records that document the medical care
1302	1302	4 and services provided to recipients of Medical Assistance
1303	1303	5 under this Article. Such records must be retained for a period
1304	1304	6 of not less than 6 years from the date of service or as
1305	1305	7 provided by applicable State law, whichever period is longer,
1306	1306	8 except that if an audit is initiated within the required
1307	1307	9 retention period then the records must be retained until the
1308	1308	10 audit is completed and every exception is resolved. The
1309	1309	11 Illinois Department shall require health care providers to
1310	1310	12 make available, when authorized by the patient, in writing,
1311	1311	13 the medical records in a timely fashion to other health care
1312	1312	14 providers who are treating or serving persons eligible for
1313	1313	15 Medical Assistance under this Article. All dispensers of
1314	1314	16 medical services shall be required to maintain and retain
1315	1315	17 business and professional records sufficient to fully and
1316	1316	18 accurately document the nature, scope, details and receipt of
1317	1317	19 the health care provided to persons eligible for medical
1318	1318	20 assistance under this Code, in accordance with regulations
1319	1319	21 promulgated by the Illinois Department. The rules and
1320	1320	22 regulations shall require that proof of the receipt of
1321	1321	23 prescription drugs, dentures, prosthetic devices and
1322	1322	24 eyeglasses by eligible persons under this Section accompany
1323	1323	25 each claim for reimbursement submitted by the dispenser of
1324	1324	26 such medical services. No such claims for reimbursement shall
1325	1325
1326	1326
1327	1327
1328	1328
1329	1329
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1331	1331
1332	1332
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1334	1334	HB1456 - 37 - LRB104 07779 KTG 17824 b
1335	1335	1 be approved for payment by the Illinois Department without
1336	1336	2 such proof of receipt, unless the Illinois Department shall
1337	1337	3 have put into effect and shall be operating a system of
1338	1338	4 post-payment audit and review which shall, on a sampling
1339	1339	5 basis, be deemed adequate by the Illinois Department to assure
1340	1340	6 that such drugs, dentures, prosthetic devices and eyeglasses
1341	1341	7 for which payment is being made are actually being received by
1342	1342	8 eligible recipients. Within 90 days after September 16, 1984
1343	1343	9 (the effective date of Public Act 83-1439), the Illinois
1344	1344	10 Department shall establish a current list of acquisition costs
1345	1345	11 for all prosthetic devices and any other items recognized as
1346	1346	12 medical equipment and supplies reimbursable under this Article
1347	1347	13 and shall update such list on a quarterly basis, except that
1348	1348	14 the acquisition costs of all prescription drugs shall be
1349	1349	15 updated no less frequently than every 30 days as required by
1350	1350	16 Section 5-5.12.
1351	1351	17 Notwithstanding any other law to the contrary, the
1352	1352	18 Illinois Department shall, within 365 days after July 22, 2013
1353	1353	19 (the effective date of Public Act 98-104), establish
1354	1354	20 procedures to permit skilled care facilities licensed under
1355	1355	21 the Nursing Home Care Act to submit monthly billing claims for
1356	1356	22 reimbursement purposes. Following development of these
1357	1357	23 procedures, the Department shall, by July 1, 2016, test the
1358	1358	24 viability of the new system and implement any necessary
1359	1359	25 operational or structural changes to its information
1360	1360	26 technology platforms in order to allow for the direct
1361	1361
1362	1362
1363	1363
1364	1364
1365	1365
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1367	1367
1368	1368
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1371	1371	1 acceptance and payment of nursing home claims.
1372	1372	2 Notwithstanding any other law to the contrary, the
1373	1373	3 Illinois Department shall, within 365 days after August 15,
1374	1374	4 2014 (the effective date of Public Act 98-963), establish
1375	1375	5 procedures to permit ID/DD facilities licensed under the ID/DD
1376	1376	6 Community Care Act and MC/DD facilities licensed under the
1377	1377	7 MC/DD Act to submit monthly billing claims for reimbursement
1378	1378	8 purposes. Following development of these procedures, the
1379	1379	9 Department shall have an additional 365 days to test the
1380	1380	10 viability of the new system and to ensure that any necessary
1381	1381	11 operational or structural changes to its information
1382	1382	12 technology platforms are implemented.
1383	1383	13 The Illinois Department shall require all dispensers of
1384	1384	14 medical services, other than an individual practitioner or
1385	1385	15 group of practitioners, desiring to participate in the Medical
1386	1386	16 Assistance program established under this Article to disclose
1387	1387	17 all financial, beneficial, ownership, equity, surety or other
1388	1388	18 interests in any and all firms, corporations, partnerships,
1389	1389	19 associations, business enterprises, joint ventures, agencies,
1390	1390	20 institutions or other legal entities providing any form of
1391	1391	21 health care services in this State under this Article.
1392	1392	22 The Illinois Department may require that all dispensers of
1393	1393	23 medical services desiring to participate in the medical
1394	1394	24 assistance program established under this Article disclose,
1395	1395	25 under such terms and conditions as the Illinois Department may
1396	1396	26 by rule establish, all inquiries from clients and attorneys
1397	1397
1398	1398
1399	1399
1400	1400
1401	1401
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1403	1403
1404	1404
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1406	1406	HB1456 - 39 - LRB104 07779 KTG 17824 b
1407	1407	1 regarding medical bills paid by the Illinois Department, which
1408	1408	2 inquiries could indicate potential existence of claims or
1409	1409	3 liens for the Illinois Department.
1410	1410	4 Enrollment of a vendor shall be subject to a provisional
1411	1411	5 period and shall be conditional for one year. During the
1412	1412	6 period of conditional enrollment, the Department may terminate
1413	1413	7 the vendor's eligibility to participate in, or may disenroll
1414	1414	8 the vendor from, the medical assistance program without cause.
1415	1415	9 Unless otherwise specified, such termination of eligibility or
1416	1416	10 disenrollment is not subject to the Department's hearing
1417	1417	11 process. However, a disenrolled vendor may reapply without
1418	1418	12 penalty.
1419	1419	13 The Department has the discretion to limit the conditional
1420	1420	14 enrollment period for vendors based upon the category of risk
1421	1421	15 of the vendor.
1422	1422	16 Prior to enrollment and during the conditional enrollment
1423	1423	17 period in the medical assistance program, all vendors shall be
1424	1424	18 subject to enhanced oversight, screening, and review based on
1425	1425	19 the risk of fraud, waste, and abuse that is posed by the
1426	1426	20 category of risk of the vendor. The Illinois Department shall
1427	1427	21 establish the procedures for oversight, screening, and review,
1428	1428	22 which may include, but need not be limited to: criminal and
1429	1429	23 financial background checks; fingerprinting; license,
1430	1430	24 certification, and authorization verifications; unscheduled or
1431	1431	25 unannounced site visits; database checks; prepayment audit
1432	1432	26 reviews; audits; payment caps; payment suspensions; and other
1433	1433
1434	1434
1435	1435
1436	1436
1437	1437
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1439	1439
1440	1440
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1443	1443	1 screening as required by federal or State law.
1444	1444	2 The Department shall define or specify the following: (i)
1445	1445	3 by provider notice, the "category of risk of the vendor" for
1446	1446	4 each type of vendor, which shall take into account the level of
1447	1447	5 screening applicable to a particular category of vendor under
1448	1448	6 federal law and regulations; (ii) by rule or provider notice,
1449	1449	7 the maximum length of the conditional enrollment period for
1450	1450	8 each category of risk of the vendor; and (iii) by rule, the
1451	1451	9 hearing rights, if any, afforded to a vendor in each category
1452	1452	10 of risk of the vendor that is terminated or disenrolled during
1453	1453	11 the conditional enrollment period.
1454	1454	12 To be eligible for payment consideration, a vendor's
1455	1455	13 payment claim or bill, either as an initial claim or as a
1456	1456	14 resubmitted claim following prior rejection, must be received
1457	1457	15 by the Illinois Department, or its fiscal intermediary, no
1458	1458	16 later than 180 days after the latest date on the claim on which
1459	1459	17 medical goods or services were provided, with the following
1460	1460	18 exceptions:
1461	1461	19 (1) In the case of a provider whose enrollment is in
1462	1462	20 process by the Illinois Department, the 180-day period
1463	1463	21 shall not begin until the date on the written notice from
1464	1464	22 the Illinois Department that the provider enrollment is
1465	1465	23 complete.
1466	1466	24 (2) In the case of errors attributable to the Illinois
1467	1467	25 Department or any of its claims processing intermediaries
1468	1468	26 which result in an inability to receive, process, or
1469	1469
1470	1470
1471	1471
1472	1472
1473	1473
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1475	1475
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1479	1479	1 adjudicate a claim, the 180-day period shall not begin
1480	1480	2 until the provider has been notified of the error.
1481	1481	3 (3) In the case of a provider for whom the Illinois
1482	1482	4 Department initiates the monthly billing process.
1483	1483	5 (4) In the case of a provider operated by a unit of
1484	1484	6 local government with a population exceeding 3,000,000
1485	1485	7 when local government funds finance federal participation
1486	1486	8 for claims payments.
1487	1487	9 For claims for services rendered during a period for which
1488	1488	10 a recipient received retroactive eligibility, claims must be
1489	1489	11 filed within 180 days after the Department determines the
1490	1490	12 applicant is eligible. For claims for which the Illinois
1491	1491	13 Department is not the primary payer, claims must be submitted
1492	1492	14 to the Illinois Department within 180 days after the final
1493	1493	15 adjudication by the primary payer.
1494	1494	16 In the case of long term care facilities, within 120
1495	1495	17 calendar days of receipt by the facility of required
1496	1496	18 prescreening information, new admissions with associated
1497	1497	19 admission documents shall be submitted through the Medical
1498	1498	20 Electronic Data Interchange (MEDI) or the Recipient
1499	1499	21 Eligibility Verification (REV) System or shall be submitted
1500	1500	22 directly to the Department of Human Services using required
1501	1501	23 admission forms. Effective September 1, 2014, admission
1502	1502	24 documents, including all prescreening information, must be
1503	1503	25 submitted through MEDI or REV. Confirmation numbers assigned
1504	1504	26 to an accepted transaction shall be retained by a facility to
1505	1505
1506	1506
1507	1507
1508	1508
1509	1509
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1511	1511
1512	1512
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1515	1515	1 verify timely submittal. Once an admission transaction has
1516	1516	2 been completed, all resubmitted claims following prior
1517	1517	3 rejection are subject to receipt no later than 180 days after
1518	1518	4 the admission transaction has been completed.
1519	1519	5 Claims that are not submitted and received in compliance
1520	1520	6 with the foregoing requirements shall not be eligible for
1521	1521	7 payment under the medical assistance program, and the State
1522	1522	8 shall have no liability for payment of those claims.
1523	1523	9 To the extent consistent with applicable information and
1524	1524	10 privacy, security, and disclosure laws, State and federal
1525	1525	11 agencies and departments shall provide the Illinois Department
1526	1526	12 access to confidential and other information and data
1527	1527	13 necessary to perform eligibility and payment verifications and
1528	1528	14 other Illinois Department functions. This includes, but is not
1529	1529	15 limited to: information pertaining to licensure;
1530	1530	16 certification; earnings; immigration status; citizenship; wage
1531	1531	17 reporting; unearned and earned income; pension income;
1532	1532	18 employment; supplemental security income; social security
1533	1533	19 numbers; National Provider Identifier (NPI) numbers; the
1534	1534	20 National Practitioner Data Bank (NPDB); program and agency
1535	1535	21 exclusions; taxpayer identification numbers; tax delinquency;
1536	1536	22 corporate information; and death records.
1537	1537	23 The Illinois Department shall enter into agreements with
1538	1538	24 State agencies and departments, and is authorized to enter
1539	1539	25 into agreements with federal agencies and departments, under
1540	1540	26 which such agencies and departments shall share data necessary
1541	1541
1542	1542
1543	1543
1544	1544
1545	1545
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1547	1547
1548	1548
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1551	1551	1 for medical assistance program integrity functions and
1552	1552	2 oversight. The Illinois Department shall develop, in
1553	1553	3 cooperation with other State departments and agencies, and in
1554	1554	4 compliance with applicable federal laws and regulations,
1555	1555	5 appropriate and effective methods to share such data. At a
1556	1556	6 minimum, and to the extent necessary to provide data sharing,
1557	1557	7 the Illinois Department shall enter into agreements with State
1558	1558	8 agencies and departments, and is authorized to enter into
1559	1559	9 agreements with federal agencies and departments, including,
1560	1560	10 but not limited to: the Secretary of State; the Department of
1561	1561	11 Revenue; the Department of Public Health; the Department of
1562	1562	12 Human Services; and the Department of Financial and
1563	1563	13 Professional Regulation.
1564	1564	14 Beginning in fiscal year 2013, the Illinois Department
1565	1565	15 shall set forth a request for information to identify the
1566	1566	16 benefits of a pre-payment, post-adjudication, and post-edit
1567	1567	17 claims system with the goals of streamlining claims processing
1568	1568	18 and provider reimbursement, reducing the number of pending or
1569	1569	19 rejected claims, and helping to ensure a more transparent
1570	1570	20 adjudication process through the utilization of: (i) provider
1571	1571	21 data verification and provider screening technology; and (ii)
1572	1572	22 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
1573	1573	23 post-adjudicated predictive modeling with an integrated case
1574	1574	24 management system with link analysis. Such a request for
1575	1575	25 information shall not be considered as a request for proposal
1576	1576	26 or as an obligation on the part of the Illinois Department to
1577	1577
1578	1578
1579	1579
1580	1580
1581	1581
1582	1582	HB1456 - 43 - LRB104 07779 KTG 17824 b
1583	1583
1584	1584
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1586	1586	HB1456 - 44 - LRB104 07779 KTG 17824 b
1587	1587	1 take any action or acquire any products or services.
1588	1588	2 The Illinois Department shall establish policies,
1589	1589	3 procedures, standards and criteria by rule for the
1590	1590	4 acquisition, repair and replacement of orthotic and prosthetic
1591	1591	5 devices and durable medical equipment. Such rules shall
1592	1592	6 provide, but not be limited to, the following services: (1)
1593	1593	7 immediate repair or replacement of such devices by recipients;
1594	1594	8 and (2) rental, lease, purchase or lease-purchase of durable
1595	1595	9 medical equipment in a cost-effective manner, taking into
1596	1596	10 consideration the recipient's medical prognosis, the extent of
1597	1597	11 the recipient's needs, and the requirements and costs for
1598	1598	12 maintaining such equipment. Subject to prior approval, such
1599	1599	13 rules shall enable a recipient to temporarily acquire and use
1600	1600	14 alternative or substitute devices or equipment pending repairs
1601	1601	15 or replacements of any device or equipment previously
1602	1602	16 authorized for such recipient by the Department.
1603	1603	17 Notwithstanding any provision of Section 5-5f to the contrary,
1604	1604	18 the Department may, by rule, exempt certain replacement
1605	1605	19 wheelchair parts from prior approval and, for wheelchairs,
1606	1606	20 wheelchair parts, wheelchair accessories, and related seating
1607	1607	21 and positioning items, determine the wholesale price by
1608	1608	22 methods other than actual acquisition costs.
1609	1609	23 The Department shall require, by rule, all providers of
1610	1610	24 durable medical equipment to be accredited by an accreditation
1611	1611	25 organization approved by the federal Centers for Medicare and
1612	1612	26 Medicaid Services and recognized by the Department in order to
1613	1613
1614	1614
1615	1615
1616	1616
1617	1617
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1619	1619
1620	1620
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1623	1623	1 bill the Department for providing durable medical equipment to
1624	1624	2 recipients. No later than 15 months after the effective date
1625	1625	3 of the rule adopted pursuant to this paragraph, all providers
1626	1626	4 must meet the accreditation requirement.
1627	1627	5 In order to promote environmental responsibility, meet the
1628	1628	6 needs of recipients and enrollees, and achieve significant
1629	1629	7 cost savings, the Department, or a managed care organization
1630	1630	8 under contract with the Department, may provide recipients or
1631	1631	9 managed care enrollees who have a prescription or Certificate
1632	1632	10 of Medical Necessity access to refurbished durable medical
1633	1633	11 equipment under this Section (excluding prosthetic and
1634	1634	12 orthotic devices as defined in the Orthotics, Prosthetics, and
1635	1635	13 Pedorthics Practice Act and complex rehabilitation technology
1636	1636	14 products and associated services) through the State's
1637	1637	15 assistive technology program's reutilization program, using
1638	1638	16 staff with the Assistive Technology Professional (ATP)
1639	1639	17 Certification if the refurbished durable medical equipment:
1640	1640	18 (i) is available; (ii) is less expensive, including shipping
1641	1641	19 costs, than new durable medical equipment of the same type;
1642	1642	20 (iii) is able to withstand at least 3 years of use; (iv) is
1643	1643	21 cleaned, disinfected, sterilized, and safe in accordance with
1644	1644	22 federal Food and Drug Administration regulations and guidance
1645	1645	23 governing the reprocessing of medical devices in health care
1646	1646	24 settings; and (v) equally meets the needs of the recipient or
1647	1647	25 enrollee. The reutilization program shall confirm that the
1648	1648	26 recipient or enrollee is not already in receipt of the same or
1649	1649
1650	1650
1651	1651
1652	1652
1653	1653
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1655	1655
1656	1656
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1658	1658	HB1456 - 46 - LRB104 07779 KTG 17824 b
1659	1659	1 similar equipment from another service provider, and that the
1660	1660	2 refurbished durable medical equipment equally meets the needs
1661	1661	3 of the recipient or enrollee. Nothing in this paragraph shall
1662	1662	4 be construed to limit recipient or enrollee choice to obtain
1663	1663	5 new durable medical equipment or place any additional prior
1664	1664	6 authorization conditions on enrollees of managed care
1665	1665	7 organizations.
1666	1666	8 The Department shall execute, relative to the nursing home
1667	1667	9 prescreening project, written inter-agency agreements with the
1668	1668	10 Department of Human Services and the Department on Aging, to
1669	1669	11 effect the following: (i) intake procedures and common
1670	1670	12 eligibility criteria for those persons who are receiving
1671	1671	13 non-institutional services; and (ii) the establishment and
1672	1672	14 development of non-institutional services in areas of the
1673	1673	15 State where they are not currently available or are
1674	1674	16 undeveloped; and (iii) notwithstanding any other provision of
1675	1675	17 law, subject to federal approval, on and after July 1, 2012, an
1676	1676	18 increase in the determination of need (DON) scores from 29 to
1677	1677	19 37 for applicants for institutional and home and
1678	1678	20 community-based long term care; if and only if federal
1679	1679	21 approval is not granted, the Department may, in conjunction
1680	1680	22 with other affected agencies, implement utilization controls
1681	1681	23 or changes in benefit packages to effectuate a similar savings
1682	1682	24 amount for this population; and (iv) no later than July 1,
1683	1683	25 2013, minimum level of care eligibility criteria for
1684	1684	26 institutional and home and community-based long term care; and
1685	1685
1686	1686
1687	1687
1688	1688
1689	1689
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1691	1691
1692	1692
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1695	1695	1 (v) no later than October 1, 2013, establish procedures to
1696	1696	2 permit long term care providers access to eligibility scores
1697	1697	3 for individuals with an admission date who are seeking or
1698	1698	4 receiving services from the long term care provider. In order
1699	1699	5 to select the minimum level of care eligibility criteria, the
1700	1700	6 Governor shall establish a workgroup that includes affected
1701	1701	7 agency representatives and stakeholders representing the
1702	1702	8 institutional and home and community-based long term care
1703	1703	9 interests. This Section shall not restrict the Department from
1704	1704	10 implementing lower level of care eligibility criteria for
1705	1705	11 community-based services in circumstances where federal
1706	1706	12 approval has been granted.
1707	1707	13 The Illinois Department shall develop and operate, in
1708	1708	14 cooperation with other State Departments and agencies and in
1709	1709	15 compliance with applicable federal laws and regulations,
1710	1710	16 appropriate and effective systems of health care evaluation
1711	1711	17 and programs for monitoring of utilization of health care
1712	1712	18 services and facilities, as it affects persons eligible for
1713	1713	19 medical assistance under this Code.
1714	1714	20 The Illinois Department shall report annually to the
1715	1715	21 General Assembly, no later than the second Friday in April of
1716	1716	22 1979 and each year thereafter, in regard to:
1717	1717	23 (a) actual statistics and trends in utilization of
1718	1718	24 medical services by public aid recipients;
1719	1719	25 (b) actual statistics and trends in the provision of
1720	1720	26 the various medical services by medical vendors;
1721	1721
1722	1722
1723	1723
1724	1724
1725	1725
1726	1726	HB1456 - 47 - LRB104 07779 KTG 17824 b
1727	1727
1728	1728
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1731	1731	1 (c) current rate structures and proposed changes in
1732	1732	2 those rate structures for the various medical vendors; and
1733	1733	3 (d) efforts at utilization review and control by the
1734	1734	4 Illinois Department.
1735	1735	5 The period covered by each report shall be the 3 years
1736	1736	6 ending on the June 30 prior to the report. The report shall
1737	1737	7 include suggested legislation for consideration by the General
1738	1738	8 Assembly. The requirement for reporting to the General
1739	1739	9 Assembly shall be satisfied by filing copies of the report as
1740	1740	10 required by Section 3.1 of the General Assembly Organization
1741	1741	11 Act, and filing such additional copies with the State
1742	1742	12 Government Report Distribution Center for the General Assembly
1743	1743	13 as is required under paragraph (t) of Section 7 of the State
1744	1744	14 Library Act.
1745	1745	15 Rulemaking authority to implement Public Act 95-1045, if
1746	1746	16 any, is conditioned on the rules being adopted in accordance
1747	1747	17 with all provisions of the Illinois Administrative Procedure
1748	1748	18 Act and all rules and procedures of the Joint Committee on
1749	1749	19 Administrative Rules; any purported rule not so adopted, for
1750	1750	20 whatever reason, is unauthorized.
1751	1751	21 On and after July 1, 2012, the Department shall reduce any
1752	1752	22 rate of reimbursement for services or other payments or alter
1753	1753	23 any methodologies authorized by this Code to reduce any rate
1754	1754	24 of reimbursement for services or other payments in accordance
1755	1755	25 with Section 5-5e.
1756	1756	26 Because kidney transplantation can be an appropriate,
1757	1757
1758	1758
1759	1759
1760	1760
1761	1761
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1763	1763
1764	1764
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1767	1767	1 cost-effective alternative to renal dialysis when medically
1768	1768	2 necessary and notwithstanding the provisions of Section 1-11
1769	1769	3 of this Code, beginning October 1, 2014, the Department shall
1770	1770	4 cover kidney transplantation for noncitizens with end-stage
1771	1771	5 renal disease who are not eligible for comprehensive medical
1772	1772	6 benefits, who meet the residency requirements of Section 5-3
1773	1773	7 of this Code, and who would otherwise meet the financial
1774	1774	8 requirements of the appropriate class of eligible persons
1775	1775	9 under Section 5-2 of this Code. To qualify for coverage of
1776	1776	10 kidney transplantation, such person must be receiving
1777	1777	11 emergency renal dialysis services covered by the Department.
1778	1778	12 Providers under this Section shall be prior approved and
1779	1779	13 certified by the Department to perform kidney transplantation
1780	1780	14 and the services under this Section shall be limited to
1781	1781	15 services associated with kidney transplantation.
1782	1782	16 Notwithstanding any other provision of this Code to the
1783	1783	17 contrary, on or after July 1, 2015, all FDA-approved FDA
1784	1784	18 approved forms of medication assisted treatment prescribed for
1785	1785	19 the treatment of alcohol dependence or treatment of opioid
1786	1786	20 dependence shall be covered under both fee-for-service and
1787	1787	21 managed care medical assistance programs for persons who are
1788	1788	22 otherwise eligible for medical assistance under this Article
1789	1789	23 and shall not be subject to any (1) utilization control, other
1790	1790	24 than those established under the American Society of Addiction
1791	1791	25 Medicine patient placement criteria, (2) prior authorization
1792	1792	26 mandate, (3) lifetime restriction limit mandate, or (4)
1793	1793
1794	1794
1795	1795
1796	1796
1797	1797
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1799	1799
1800	1800
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1803	1803	1 limitations on dosage.
1804	1804	2 On or after July 1, 2015, opioid antagonists prescribed
1805	1805	3 for the treatment of an opioid overdose, including the
1806	1806	4 medication product, administration devices, and any pharmacy
1807	1807	5 fees or hospital fees related to the dispensing, distribution,
1808	1808	6 and administration of the opioid antagonist, shall be covered
1809	1809	7 under the medical assistance program for persons who are
1810	1810	8 otherwise eligible for medical assistance under this Article.
1811	1811	9 As used in this Section, "opioid antagonist" means a drug that
1812	1812	10 binds to opioid receptors and blocks or inhibits the effect of
1813	1813	11 opioids acting on those receptors, including, but not limited
1814	1814	12 to, naloxone hydrochloride or any other similarly acting drug
1815	1815	13 approved by the U.S. Food and Drug Administration. The
1816	1816	14 Department shall not impose a copayment on the coverage
1817	1817	15 provided for naloxone hydrochloride under the medical
1818	1818	16 assistance program.
1819	1819	17 Upon federal approval, the Department shall provide
1820	1820	18 coverage and reimbursement for all drugs that are approved for
1821	1821	19 marketing by the federal Food and Drug Administration and that
1822	1822	20 are recommended by the federal Public Health Service or the
1823	1823	21 United States Centers for Disease Control and Prevention for
1824	1824	22 pre-exposure prophylaxis and related pre-exposure prophylaxis
1825	1825	23 services, including, but not limited to, HIV and sexually
1826	1826	24 transmitted infection screening, treatment for sexually
1827	1827	25 transmitted infections, medical monitoring, assorted labs, and
1828	1828	26 counseling to reduce the likelihood of HIV infection among
1829	1829
1830	1830
1831	1831
1832	1832
1833	1833
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1835	1835
1836	1836
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1838	1838	HB1456 - 51 - LRB104 07779 KTG 17824 b
1839	1839	1 individuals who are not infected with HIV but who are at high
1840	1840	2 risk of HIV infection.
1841	1841	3 A federally qualified health center, as defined in Section
1842	1842	4 1905(l)(2)(B) of the federal Social Security Act, shall be
1843	1843	5 reimbursed by the Department in accordance with the federally
1844	1844	6 qualified health center's encounter rate for services provided
1845	1845	7 to medical assistance recipients that are performed by a
1846	1846	8 dental hygienist, as defined under the Illinois Dental
1847	1847	9 Practice Act, working under the general supervision of a
1848	1848	10 dentist and employed by a federally qualified health center.
1849	1849	11 Within 90 days after October 8, 2021 (the effective date
1850	1850	12 of Public Act 102-665), the Department shall seek federal
1851	1851	13 approval of a State Plan amendment to expand coverage for
1852	1852	14 family planning services that includes presumptive eligibility
1853	1853	15 to individuals whose income is at or below 208% of the federal
1854	1854	16 poverty level. Coverage under this Section shall be effective
1855	1855	17 beginning no later than December 1, 2022.
1856	1856	18 Subject to approval by the federal Centers for Medicare
1857	1857	19 and Medicaid Services of a Title XIX State Plan amendment
1858	1858	20 electing the Program of All-Inclusive Care for the Elderly
1859	1859	21 (PACE) as a State Medicaid option, as provided for by Subtitle
1860	1860	22 I (commencing with Section 4801) of Title IV of the Balanced
1861	1861	23 Budget Act of 1997 (Public Law 105-33) and Part 460
1862	1862	24 (commencing with Section 460.2) of Subchapter E of Title 42 of
1863	1863	25 the Code of Federal Regulations, PACE program services shall
1864	1864	26 become a covered benefit of the medical assistance program,
1865	1865
1866	1866
1867	1867
1868	1868
1869	1869
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1871	1871
1872	1872
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1875	1875	1 subject to criteria established in accordance with all
1876	1876	2 applicable laws.
1877	1877	3 Notwithstanding any other provision of this Code,
1878	1878	4 community-based pediatric palliative care from a trained
1879	1879	5 interdisciplinary team shall be covered under the medical
1880	1880	6 assistance program as provided in Section 15 of the Pediatric
1881	1881	7 Palliative Care Act.
1882	1882	8 Notwithstanding any other provision of this Code, within
1883	1883	9 12 months after June 2, 2022 (the effective date of Public Act
1884	1884	10 102-1037) and subject to federal approval, acupuncture
1885	1885	11 services performed by an acupuncturist licensed under the
1886	1886	12 Acupuncture Practice Act who is acting within the scope of his
1887	1887	13 or her license shall be covered under the medical assistance
1888	1888	14 program. The Department shall apply for any federal waiver or
1889	1889	15 State Plan amendment, if required, to implement this
1890	1890	16 paragraph. The Department may adopt any rules, including
1891	1891	17 standards and criteria, necessary to implement this paragraph.
1892	1892	18 Notwithstanding any other provision of this Code, the
1893	1893	19 medical assistance program shall, subject to federal approval,
1894	1894	20 reimburse hospitals for costs associated with a newborn
1895	1895	21 screening test for the presence of metachromatic
1896	1896	22 leukodystrophy, as required under the Newborn Metabolic
1897	1897	23 Screening Act, at a rate not less than the fee charged by the
1898	1898	24 Department of Public Health. Notwithstanding any other
1899	1899	25 provision of this Code, the medical assistance program shall,
1900	1900	26 subject to appropriation and federal approval, also reimburse
1901	1901
1902	1902
1903	1903
1904	1904
1905	1905
1906	1906	HB1456 - 52 - LRB104 07779 KTG 17824 b
1907	1907
1908	1908
1909	1909	HB1456- 53 -LRB104 07779 KTG 17824 b HB1456 - 53 - LRB104 07779 KTG 17824 b
1910	1910	HB1456 - 53 - LRB104 07779 KTG 17824 b
1911	1911	1 hospitals for costs associated with all newborn screening
1912	1912	2 tests added on and after August 9, 2024 (the effective date of
1913	1913	3 Public Act 103-909) this amendatory Act of the 103rd General
1914	1914	4 Assembly to the Newborn Metabolic Screening Act and required
1915	1915	5 to be performed under that Act at a rate not less than the fee
1916	1916	6 charged by the Department of Public Health. The Department
1917	1917	7 shall seek federal approval before the implementation of the
1918	1918	8 newborn screening test fees by the Department of Public
1919	1919	9 Health.
1920	1920	10 Notwithstanding any other provision of this Code,
1921	1921	11 beginning on January 1, 2024, subject to federal approval,
1922	1922	12 cognitive assessment and care planning services provided to a
1923	1923	13 person who experiences signs or symptoms of cognitive
1924	1924	14 impairment, as defined by the Diagnostic and Statistical
1925	1925	15 Manual of Mental Disorders, Fifth Edition, shall be covered
1926	1926	16 under the medical assistance program for persons who are
1927	1927	17 otherwise eligible for medical assistance under this Article.
1928	1928	18 Notwithstanding any other provision of this Code,
1929	1929	19 medically necessary reconstructive services that are intended
1930	1930	20 to restore physical appearance shall be covered under the
1931	1931	21 medical assistance program for persons who are otherwise
1932	1932	22 eligible for medical assistance under this Article. As used in
1933	1933	23 this paragraph, "reconstructive services" means treatments
1934	1934	24 performed on structures of the body damaged by trauma to
1935	1935	25 restore physical appearance.
1936	1936	26 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1937	1937
1938	1938
1939	1939
1940	1940
1941	1941
1942	1942	HB1456 - 53 - LRB104 07779 KTG 17824 b
1943	1943
1944	1944
1945	1945	HB1456- 54 -LRB104 07779 KTG 17824 b HB1456 - 54 - LRB104 07779 KTG 17824 b
1946	1946	HB1456 - 54 - LRB104 07779 KTG 17824 b
1947	1947	1 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1948	1948	2 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1949	1949	3 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1950	1950	4 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1951	1951	5 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1952	1952	6 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1953	1953	7 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1954	1954	8 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1955	1955	9 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
1956	1956	10 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
1957	1957	11 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
1958	1958	12 10-10-24.)
1959	1959	13 (Text of Section after amendment by P.A. 103-808)
1960	1960	14 Sec. 5-5. Medical services. The Illinois Department, by
1961	1961	15 rule, shall determine the quantity and quality of and the rate
1962	1962	16 of reimbursement for the medical assistance for which payment
1963	1963	17 will be authorized, and the medical services to be provided,
1964	1964	18 which may include all or part of the following: (1) inpatient
1965	1965	19 hospital services; (2) outpatient hospital services; (3) other
1966	1966	20 laboratory and X-ray services; (4) skilled nursing home
1967	1967	21 services; (5) physicians' services whether furnished in the
1968	1968	22 office, the patient's home, a hospital, a skilled nursing
1969	1969	23 home, or elsewhere; (6) medical care, or any other type of
1970	1970	24 remedial care furnished by licensed practitioners; (7) home
1971	1971	25 health care services; (8) private duty nursing service; (9)
1972	1972
1973	1973
1974	1974
1975	1975
1976	1976
1977	1977	HB1456 - 54 - LRB104 07779 KTG 17824 b
1978	1978
1979	1979
1980	1980	HB1456- 55 -LRB104 07779 KTG 17824 b HB1456 - 55 - LRB104 07779 KTG 17824 b
1981	1981	HB1456 - 55 - LRB104 07779 KTG 17824 b
1982	1982	1 clinic services; (10) dental services, including prevention
1983	1983	2 and treatment of periodontal disease and dental caries disease
1984	1984	3 for pregnant individuals, provided by an individual licensed
1985	1985	4 to practice dentistry or dental surgery; for purposes of this
1986	1986	5 item (10), "dental services" means diagnostic, preventive, or
1987	1987	6 corrective procedures provided by or under the supervision of
1988	1988	7 a dentist in the practice of his or her profession; (11)
1989	1989	8 physical therapy and related services; (12) prescribed drugs,
1990	1990	9 dentures, and prosthetic devices; and eyeglasses prescribed by
1991	1991	10 a physician skilled in the diseases of the eye, or by an
1992	1992	11 optometrist, whichever the person may select; (13) other
1993	1993	12 diagnostic, screening, preventive, and rehabilitative
1994	1994	13 services, including to ensure that the individual's need for
1995	1995	14 intervention or treatment of mental disorders or substance use
1996	1996	15 disorders or co-occurring mental health and substance use
1997	1997	16 disorders is determined using a uniform screening, assessment,
1998	1998	17 and evaluation process inclusive of criteria, for children and
1999	1999	18 adults; for purposes of this item (13), a uniform screening,
2000	2000	19 assessment, and evaluation process refers to a process that
2001	2001	20 includes an appropriate evaluation and, as warranted, a
2002	2002	21 referral; "uniform" does not mean the use of a singular
2003	2003	22 instrument, tool, or process that all must utilize; (14)
2004	2004	23 transportation and such other expenses as may be necessary;
2005	2005	24 (15) medical treatment of sexual assault survivors, as defined
2006	2006	25 in Section 1a of the Sexual Assault Survivors Emergency
2007	2007	26 Treatment Act, for injuries sustained as a result of the
2008	2008
2009	2009
2010	2010
2011	2011
2012	2012
2013	2013	HB1456 - 55 - LRB104 07779 KTG 17824 b
2014	2014
2015	2015
2016	2016	HB1456- 56 -LRB104 07779 KTG 17824 b HB1456 - 56 - LRB104 07779 KTG 17824 b
2017	2017	HB1456 - 56 - LRB104 07779 KTG 17824 b
2018	2018	1 sexual assault, including examinations and laboratory tests to
2019	2019	2 discover evidence which may be used in criminal proceedings
2020	2020	3 arising from the sexual assault; (16) the diagnosis and
2021	2021	4 treatment of sickle cell anemia; (16.5) services performed by
2022	2022	5 a chiropractic physician licensed under the Medical Practice
2023	2023	6 Act of 1987 and acting within the scope of his or her license,
2024	2024	7 including, but not limited to, chiropractic manipulative
2025	2025	8 treatment; and (17) any other medical care, and any other type
2026	2026	9 of remedial care recognized under the laws of this State. The
2027	2027	10 term "any other type of remedial care" shall include nursing
2028	2028	11 care and nursing home service for persons who rely on
2029	2029	12 treatment by spiritual means alone through prayer for healing.
2030	2030	13 Notwithstanding any other provision of this Section, a
2031	2031	14 comprehensive tobacco use cessation program that includes
2032	2032	15 purchasing prescription drugs or prescription medical devices
2033	2033	16 approved by the Food and Drug Administration shall be covered
2034	2034	17 under the medical assistance program under this Article for
2035	2035	18 persons who are otherwise eligible for assistance under this
2036	2036	19 Article.
2037	2037	20 Notwithstanding any other provision of this Code,
2038	2038	21 reproductive health care that is otherwise legal in Illinois
2039	2039	22 shall be covered under the medical assistance program for
2040	2040	23 persons who are otherwise eligible for medical assistance
2041	2041	24 under this Article.
2042	2042	25 Notwithstanding any other provision of this Section, all
2043	2043	26 tobacco cessation medications approved by the United States
2044	2044
2045	2045
2046	2046
2047	2047
2048	2048
2049	2049	HB1456 - 56 - LRB104 07779 KTG 17824 b
2050	2050
2051	2051
2052	2052	HB1456- 57 -LRB104 07779 KTG 17824 b HB1456 - 57 - LRB104 07779 KTG 17824 b
2053	2053	HB1456 - 57 - LRB104 07779 KTG 17824 b
2054	2054	1 Food and Drug Administration and all individual and group
2055	2055	2 tobacco cessation counseling services and telephone-based
2056	2056	3 counseling services and tobacco cessation medications provided
2057	2057	4 through the Illinois Tobacco Quitline shall be covered under
2058	2058	5 the medical assistance program for persons who are otherwise
2059	2059	6 eligible for assistance under this Article. The Department
2060	2060	7 shall comply with all federal requirements necessary to obtain
2061	2061	8 federal financial participation, as specified in 42 CFR
2062	2062	9 433.15(b)(7), for telephone-based counseling services provided
2063	2063	10 through the Illinois Tobacco Quitline, including, but not
2064	2064	11 limited to: (i) entering into a memorandum of understanding or
2065	2065	12 interagency agreement with the Department of Public Health, as
2066	2066	13 administrator of the Illinois Tobacco Quitline; and (ii)
2067	2067	14 developing a cost allocation plan for Medicaid-allowable
2068	2068	15 Illinois Tobacco Quitline services in accordance with 45 CFR
2069	2069	16 95.507. The Department shall submit the memorandum of
2070	2070	17 understanding or interagency agreement, the cost allocation
2071	2071	18 plan, and all other necessary documentation to the Centers for
2072	2072	19 Medicare and Medicaid Services for review and approval.
2073	2073	20 Coverage under this paragraph shall be contingent upon federal
2074	2074	21 approval.
2075	2075	22 Notwithstanding any other provision of this Code, the
2076	2076	23 Illinois Department may not require, as a condition of payment
2077	2077	24 for any laboratory test authorized under this Article, that a
2078	2078	25 physician's handwritten signature appear on the laboratory
2079	2079	26 test order form. The Illinois Department may, however, impose
2080	2080
2081	2081
2082	2082
2083	2083
2084	2084
2085	2085	HB1456 - 57 - LRB104 07779 KTG 17824 b
2086	2086
2087	2087
2088	2088	HB1456- 58 -LRB104 07779 KTG 17824 b HB1456 - 58 - LRB104 07779 KTG 17824 b
2089	2089	HB1456 - 58 - LRB104 07779 KTG 17824 b
2090	2090	1 other appropriate requirements regarding laboratory test order
2091	2091	2 documentation.
2092	2092	3 Upon receipt of federal approval of an amendment to the
2093	2093	4 Illinois Title XIX State Plan for this purpose, the Department
2094	2094	5 shall authorize the Chicago Public Schools (CPS) to procure a
2095	2095	6 vendor or vendors to manufacture eyeglasses for individuals
2096	2096	7 enrolled in a school within the CPS system. CPS shall ensure
2097	2097	8 that its vendor or vendors are enrolled as providers in the
2098	2098	9 medical assistance program and in any capitated Medicaid
2099	2099	10 managed care entity (MCE) serving individuals enrolled in a
2100	2100	11 school within the CPS system. Under any contract procured
2101	2101	12 under this provision, the vendor or vendors must serve only
2102	2102	13 individuals enrolled in a school within the CPS system. Claims
2103	2103	14 for services provided by CPS's vendor or vendors to recipients
2104	2104	15 of benefits in the medical assistance program under this Code,
2105	2105	16 the Children's Health Insurance Program, or the Covering ALL
2106	2106	17 KIDS Health Insurance Program shall be submitted to the
2107	2107	18 Department or the MCE in which the individual is enrolled for
2108	2108	19 payment and shall be reimbursed at the Department's or the
2109	2109	20 MCE's established rates or rate methodologies for eyeglasses.
2110	2110	21 On and after July 1, 2012, the Department of Healthcare
2111	2111	22 and Family Services may provide the following services to
2112	2112	23 persons eligible for assistance under this Article who are
2113	2113	24 participating in education, training or employment programs
2114	2114	25 operated by the Department of Human Services as successor to
2115	2115	26 the Department of Public Aid:
2116	2116
2117	2117
2118	2118
2119	2119
2120	2120
2121	2121	HB1456 - 58 - LRB104 07779 KTG 17824 b
2122	2122
2123	2123
2124	2124	HB1456- 59 -LRB104 07779 KTG 17824 b HB1456 - 59 - LRB104 07779 KTG 17824 b
2125	2125	HB1456 - 59 - LRB104 07779 KTG 17824 b
2126	2126	1 (1) dental services provided by or under the
2127	2127	2 supervision of a dentist; and
2128	2128	3 (2) eyeglasses prescribed by a physician skilled in
2129	2129	4 the diseases of the eye, or by an optometrist, whichever
2130	2130	5 the person may select.
2131	2131	6 On and after July 1, 2018, the Department of Healthcare
2132	2132	7 and Family Services shall provide dental services to any adult
2133	2133	8 who is otherwise eligible for assistance under the medical
2134	2134	9 assistance program. As used in this paragraph, "dental
2135	2135	10 services" means diagnostic, preventative, restorative, or
2136	2136	11 corrective procedures, including procedures and services for
2137	2137	12 the prevention and treatment of periodontal disease and dental
2138	2138	13 caries disease, provided by an individual who is licensed to
2139	2139	14 practice dentistry or dental surgery or who is under the
2140	2140	15 supervision of a dentist in the practice of his or her
2141	2141	16 profession.
2142	2142	17 On and after July 1, 2018, targeted dental services, as
2143	2143	18 set forth in Exhibit D of the Consent Decree entered by the
2144	2144	19 United States District Court for the Northern District of
2145	2145	20 Illinois, Eastern Division, in the matter of Memisovski v.
2146	2146	21 Maram, Case No. 92 C 1982, that are provided to adults under
2147	2147	22 the medical assistance program shall be established at no less
2148	2148	23 than the rates set forth in the "New Rate" column in Exhibit D
2149	2149	24 of the Consent Decree for targeted dental services that are
2150	2150	25 provided to persons under the age of 18 under the medical
2151	2151	26 assistance program.
2152	2152
2153	2153
2154	2154
2155	2155
2156	2156
2157	2157	HB1456 - 59 - LRB104 07779 KTG 17824 b
2158	2158
2159	2159
2160	2160	HB1456- 60 -LRB104 07779 KTG 17824 b HB1456 - 60 - LRB104 07779 KTG 17824 b
2161	2161	HB1456 - 60 - LRB104 07779 KTG 17824 b
2162	2162	1 Subject to federal approval, on and after January 1, 2025,
2163	2163	2 the rates paid for sedation evaluation and the provision of
2164	2164	3 deep sedation and intravenous sedation for the purpose of
2165	2165	4 dental services shall be increased by 33% above the rates in
2166	2166	5 effect on December 31, 2024. The rates paid for nitrous oxide
2167	2167	6 sedation shall not be impacted by this paragraph and shall
2168	2168	7 remain the same as the rates in effect on December 31, 2024.
2169	2169	8 Notwithstanding any other provision of this Code and
2170	2170	9 subject to federal approval, the Department may adopt rules to
2171	2171	10 allow a dentist who is volunteering his or her service at no
2172	2172	11 cost to render dental services through an enrolled
2173	2173	12 not-for-profit health clinic without the dentist personally
2174	2174	13 enrolling as a participating provider in the medical
2175	2175	14 assistance program. A not-for-profit health clinic shall
2176	2176	15 include a public health clinic or Federally Qualified Health
2177	2177	16 Center or other enrolled provider, as determined by the
2178	2178	17 Department, through which dental services covered under this
2179	2179	18 Section are performed. The Department shall establish a
2180	2180	19 process for payment of claims for reimbursement for covered
2181	2181	20 dental services rendered under this provision.
2182	2182	21 Subject to appropriation and to federal approval, the
2183	2183	22 Department shall file administrative rules updating the
2184	2184	23 Handicapping Labio-Lingual Deviation orthodontic scoring tool
2185	2185	24 by January 1, 2025, or as soon as practicable.
2186	2186	25 On and after January 1, 2022, the Department of Healthcare
2187	2187	26 and Family Services shall administer and regulate a
2188	2188
2189	2189
2190	2190
2191	2191
2192	2192
2193	2193	HB1456 - 60 - LRB104 07779 KTG 17824 b
2194	2194
2195	2195
2196	2196	HB1456- 61 -LRB104 07779 KTG 17824 b HB1456 - 61 - LRB104 07779 KTG 17824 b
2197	2197	HB1456 - 61 - LRB104 07779 KTG 17824 b
2198	2198	1 school-based dental program that allows for the out-of-office
2199	2199	2 delivery of preventative dental services in a school setting
2200	2200	3 to children under 19 years of age. The Department shall
2201	2201	4 establish, by rule, guidelines for participation by providers
2202	2202	5 and set requirements for follow-up referral care based on the
2203	2203	6 requirements established in the Dental Office Reference Manual
2204	2204	7 published by the Department that establishes the requirements
2205	2205	8 for dentists participating in the All Kids Dental School
2206	2206	9 Program. Every effort shall be made by the Department when
2207	2207	10 developing the program requirements to consider the different
2208	2208	11 geographic differences of both urban and rural areas of the
2209	2209	12 State for initial treatment and necessary follow-up care. No
2210	2210	13 provider shall be charged a fee by any unit of local government
2211	2211	14 to participate in the school-based dental program administered
2212	2212	15 by the Department. Nothing in this paragraph shall be
2213	2213	16 construed to limit or preempt a home rule unit's or school
2214	2214	17 district's authority to establish, change, or administer a
2215	2215	18 school-based dental program in addition to, or independent of,
2216	2216	19 the school-based dental program administered by the
2217	2217	20 Department.
2218	2218	21 The Illinois Department, by rule, may distinguish and
2219	2219	22 classify the medical services to be provided only in
2220	2220	23 accordance with the classes of persons designated in Section
2221	2221	24 5-2.
2222	2222	25 The Department of Healthcare and Family Services must
2223	2223	26 provide coverage and reimbursement for amino acid-based
2224	2224
2225	2225
2226	2226
2227	2227
2228	2228
2229	2229	HB1456 - 61 - LRB104 07779 KTG 17824 b
2230	2230
2231	2231
2232	2232	HB1456- 62 -LRB104 07779 KTG 17824 b HB1456 - 62 - LRB104 07779 KTG 17824 b
2233	2233	HB1456 - 62 - LRB104 07779 KTG 17824 b
2234	2234	1 elemental formulas, regardless of delivery method, for the
2235	2235	2 diagnosis and treatment of (i) eosinophilic disorders and (ii)
2236	2236	3 short bowel syndrome when the prescribing physician has issued
2237	2237	4 a written order stating that the amino acid-based elemental
2238	2238	5 formula is medically necessary.
2239	2239	6 The Illinois Department shall authorize the provision of,
2240	2240	7 and shall authorize payment for, screening by low-dose
2241	2241	8 mammography for the presence of occult breast cancer for
2242	2242	9 individuals 35 years of age or older who are eligible for
2243	2243	10 medical assistance under this Article, as follows:
2244	2244	11 (A) A baseline mammogram for individuals 35 to 39
2245	2245	12 years of age.
2246	2246	13 (B) An annual mammogram for individuals 40 years of
2247	2247	14 age or older.
2248	2248	15 (C) A mammogram at the age and intervals considered
2249	2249	16 medically necessary by the individual's health care
2250	2250	17 provider for individuals under 40 years of age and having
2251	2251	18 a family history of breast cancer, prior personal history
2252	2252	19 of breast cancer, positive genetic testing, or other risk
2253	2253	20 factors.
2254	2254	21 (D) A comprehensive ultrasound screening and MRI of an
2255	2255	22 entire breast or breasts if a mammogram demonstrates
2256	2256	23 heterogeneous or dense breast tissue or when medically
2257	2257	24 necessary as determined by a physician licensed to
2258	2258	25 practice medicine in all of its branches.
2259	2259	26 (E) A screening MRI when medically necessary, as
2260	2260
2261	2261
2262	2262
2263	2263
2264	2264
2265	2265	HB1456 - 62 - LRB104 07779 KTG 17824 b
2266	2266
2267	2267
2268	2268	HB1456- 63 -LRB104 07779 KTG 17824 b HB1456 - 63 - LRB104 07779 KTG 17824 b
2269	2269	HB1456 - 63 - LRB104 07779 KTG 17824 b
2270	2270	1 determined by a physician licensed to practice medicine in
2271	2271	2 all of its branches.
2272	2272	3 (F) A diagnostic mammogram when medically necessary,
2273	2273	4 as determined by a physician licensed to practice medicine
2274	2274	5 in all its branches, advanced practice registered nurse,
2275	2275	6 or physician assistant.
2276	2276	7 (G) Molecular breast imaging (MBI) and MRI of an
2277	2277	8 entire breast or breasts if a mammogram demonstrates
2278	2278	9 heterogeneous or dense breast tissue or when medically
2279	2279	10 necessary as determined by a physician licensed to
2280	2280	11 practice medicine in all of its branches, advanced
2281	2281	12 practice registered nurse, or physician assistant.
2282	2282	13 The Department shall not impose a deductible, coinsurance,
2283	2283	14 copayment, or any other cost-sharing requirement on the
2284	2284	15 coverage provided under this paragraph; except that this
2285	2285	16 sentence does not apply to coverage of diagnostic mammograms
2286	2286	17 to the extent such coverage would disqualify a high-deductible
2287	2287	18 health plan from eligibility for a health savings account
2288	2288	19 pursuant to Section 223 of the Internal Revenue Code (26
2289	2289	20 U.S.C. 223).
2290	2290	21 All screenings shall include a physical breast exam,
2291	2291	22 instruction on self-examination and information regarding the
2292	2292	23 frequency of self-examination and its value as a preventative
2293	2293	24 tool.
2294	2294	25 For purposes of this Section:
2295	2295	26 "Diagnostic mammogram" means a mammogram obtained using
2296	2296
2297	2297
2298	2298
2299	2299
2300	2300
2301	2301	HB1456 - 63 - LRB104 07779 KTG 17824 b
2302	2302
2303	2303
2304	2304	HB1456- 64 -LRB104 07779 KTG 17824 b HB1456 - 64 - LRB104 07779 KTG 17824 b
2305	2305	HB1456 - 64 - LRB104 07779 KTG 17824 b
2306	2306	1 diagnostic mammography.
2307	2307	2 "Diagnostic mammography" means a method of screening that
2308	2308	3 is designed to evaluate an abnormality in a breast, including
2309	2309	4 an abnormality seen or suspected on a screening mammogram or a
2310	2310	5 subjective or objective abnormality otherwise detected in the
2311	2311	6 breast.
2312	2312	7 "Low-dose mammography" means the x-ray examination of the
2313	2313	8 breast using equipment dedicated specifically for mammography,
2314	2314	9 including the x-ray tube, filter, compression device, and
2315	2315	10 image receptor, with an average radiation exposure delivery of
2316	2316	11 less than one rad per breast for 2 views of an average size
2317	2317	12 breast. The term also includes digital mammography and
2318	2318	13 includes breast tomosynthesis.
2319	2319	14 "Breast tomosynthesis" means a radiologic procedure that
2320	2320	15 involves the acquisition of projection images over the
2321	2321	16 stationary breast to produce cross-sectional digital
2322	2322	17 three-dimensional images of the breast.
2323	2323	18 If, at any time, the Secretary of the United States
2324	2324	19 Department of Health and Human Services, or its successor
2325	2325	20 agency, promulgates rules or regulations to be published in
2326	2326	21 the Federal Register or publishes a comment in the Federal
2327	2327	22 Register or issues an opinion, guidance, or other action that
2328	2328	23 would require the State, pursuant to any provision of the
2329	2329	24 Patient Protection and Affordable Care Act (Public Law
2330	2330	25 111-148), including, but not limited to, 42 U.S.C.
2331	2331	26 18031(d)(3)(B) or any successor provision, to defray the cost
2332	2332
2333	2333
2334	2334
2335	2335
2336	2336
2337	2337	HB1456 - 64 - LRB104 07779 KTG 17824 b
2338	2338
2339	2339
2340	2340	HB1456- 65 -LRB104 07779 KTG 17824 b HB1456 - 65 - LRB104 07779 KTG 17824 b
2341	2341	HB1456 - 65 - LRB104 07779 KTG 17824 b
2342	2342	1 of any coverage for breast tomosynthesis outlined in this
2343	2343	2 paragraph, then the requirement that an insurer cover breast
2344	2344	3 tomosynthesis is inoperative other than any such coverage
2345	2345	4 authorized under Section 1902 of the Social Security Act, 42
2346	2346	5 U.S.C. 1396a, and the State shall not assume any obligation
2347	2347	6 for the cost of coverage for breast tomosynthesis set forth in
2348	2348	7 this paragraph.
2349	2349	8 On and after January 1, 2016, the Department shall ensure
2350	2350	9 that all networks of care for adult clients of the Department
2351	2351	10 include access to at least one breast imaging Center of
2352	2352	11 Imaging Excellence as certified by the American College of
2353	2353	12 Radiology.
2354	2354	13 On and after January 1, 2012, providers participating in a
2355	2355	14 quality improvement program approved by the Department shall
2356	2356	15 be reimbursed for screening and diagnostic mammography at the
2357	2357	16 same rate as the Medicare program's rates, including the
2358	2358	17 increased reimbursement for digital mammography and, after
2359	2359	18 January 1, 2023 (the effective date of Public Act 102-1018),
2360	2360	19 breast tomosynthesis.
2361	2361	20 The Department shall convene an expert panel including
2362	2362	21 representatives of hospitals, free-standing mammography
2363	2363	22 facilities, and doctors, including radiologists, to establish
2364	2364	23 quality standards for mammography.
2365	2365	24 On and after January 1, 2017, providers participating in a
2366	2366	25 breast cancer treatment quality improvement program approved
2367	2367	26 by the Department shall be reimbursed for breast cancer
2368	2368
2369	2369
2370	2370
2371	2371
2372	2372
2373	2373	HB1456 - 65 - LRB104 07779 KTG 17824 b
2374	2374
2375	2375
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2377	2377	HB1456 - 66 - LRB104 07779 KTG 17824 b
2378	2378	1 treatment at a rate that is no lower than 95% of the Medicare
2379	2379	2 program's rates for the data elements included in the breast
2380	2380	3 cancer treatment quality program.
2381	2381	4 The Department shall convene an expert panel, including
2382	2382	5 representatives of hospitals, free-standing breast cancer
2383	2383	6 treatment centers, breast cancer quality organizations, and
2384	2384	7 doctors, including radiologists that are trained in all forms
2385	2385	8 of FDA-approved FDA approved breast imaging technologies,
2386	2386	9 breast surgeons, reconstructive breast surgeons, oncologists,
2387	2387	10 and primary care providers to establish quality standards for
2388	2388	11 breast cancer treatment.
2389	2389	12 Subject to federal approval, the Department shall
2390	2390	13 establish a rate methodology for mammography at federally
2391	2391	14 qualified health centers and other encounter-rate clinics.
2392	2392	15 These clinics or centers may also collaborate with other
2393	2393	16 hospital-based mammography facilities. By January 1, 2016, the
2394	2394	17 Department shall report to the General Assembly on the status
2395	2395	18 of the provision set forth in this paragraph.
2396	2396	19 The Department shall establish a methodology to remind
2397	2397	20 individuals who are age-appropriate for screening mammography,
2398	2398	21 but who have not received a mammogram within the previous 18
2399	2399	22 months, of the importance and benefit of screening
2400	2400	23 mammography. The Department shall work with experts in breast
2401	2401	24 cancer outreach and patient navigation to optimize these
2402	2402	25 reminders and shall establish a methodology for evaluating
2403	2403	26 their effectiveness and modifying the methodology based on the
2404	2404
2405	2405
2406	2406
2407	2407
2408	2408
2409	2409	HB1456 - 66 - LRB104 07779 KTG 17824 b
2410	2410
2411	2411
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2413	2413	HB1456 - 67 - LRB104 07779 KTG 17824 b
2414	2414	1 evaluation.
2415	2415	2 The Department shall establish a performance goal for
2416	2416	3 primary care providers with respect to their female patients
2417	2417	4 over age 40 receiving an annual mammogram. This performance
2418	2418	5 goal shall be used to provide additional reimbursement in the
2419	2419	6 form of a quality performance bonus to primary care providers
2420	2420	7 who meet that goal.
2421	2421	8 The Department shall devise a means of case-managing or
2422	2422	9 patient navigation for beneficiaries diagnosed with breast
2423	2423	10 cancer. This program shall initially operate as a pilot
2424	2424	11 program in areas of the State with the highest incidence of
2425	2425	12 mortality related to breast cancer. At least one pilot program
2426	2426	13 site shall be in the metropolitan Chicago area and at least one
2427	2427	14 site shall be outside the metropolitan Chicago area. On or
2428	2428	15 after July 1, 2016, the pilot program shall be expanded to
2429	2429	16 include one site in western Illinois, one site in southern
2430	2430	17 Illinois, one site in central Illinois, and 4 sites within
2431	2431	18 metropolitan Chicago. An evaluation of the pilot program shall
2432	2432	19 be carried out measuring health outcomes and cost of care for
2433	2433	20 those served by the pilot program compared to similarly
2434	2434	21 situated patients who are not served by the pilot program.
2435	2435	22 The Department shall require all networks of care to
2436	2436	23 develop a means either internally or by contract with experts
2437	2437	24 in navigation and community outreach to navigate cancer
2438	2438	25 patients to comprehensive care in a timely fashion. The
2439	2439	26 Department shall require all networks of care to include
2440	2440
2441	2441
2442	2442
2443	2443
2444	2444
2445	2445	HB1456 - 67 - LRB104 07779 KTG 17824 b
2446	2446
2447	2447
2448	2448	HB1456- 68 -LRB104 07779 KTG 17824 b HB1456 - 68 - LRB104 07779 KTG 17824 b
2449	2449	HB1456 - 68 - LRB104 07779 KTG 17824 b
2450	2450	1 access for patients diagnosed with cancer to at least one
2451	2451	2 academic commission on cancer-accredited cancer program as an
2452	2452	3 in-network covered benefit.
2453	2453	4 The Department shall provide coverage and reimbursement
2454	2454	5 for a human papillomavirus (HPV) vaccine that is approved for
2455	2455	6 marketing by the federal Food and Drug Administration for all
2456	2456	7 persons between the ages of 9 and 45. Subject to federal
2457	2457	8 approval, the Department shall provide coverage and
2458	2458	9 reimbursement for a human papillomavirus (HPV) vaccine for
2459	2459	10 persons of the age of 46 and above who have been diagnosed with
2460	2460	11 cervical dysplasia with a high risk of recurrence or
2461	2461	12 progression. The Department shall disallow any
2462	2462	13 preauthorization requirements for the administration of the
2463	2463	14 human papillomavirus (HPV) vaccine.
2464	2464	15 On or after July 1, 2022, individuals who are otherwise
2465	2465	16 eligible for medical assistance under this Article shall
2466	2466	17 receive coverage for perinatal depression screenings for the
2467	2467	18 12-month period beginning on the last day of their pregnancy.
2468	2468	19 Medical assistance coverage under this paragraph shall be
2469	2469	20 conditioned on the use of a screening instrument approved by
2470	2470	21 the Department.
2471	2471	22 Any medical or health care provider shall immediately
2472	2472	23 recommend, to any pregnant individual who is being provided
2473	2473	24 prenatal services and is suspected of having a substance use
2474	2474	25 disorder as defined in the Substance Use Disorder Act,
2475	2475	26 referral to a local substance use disorder treatment program
2476	2476
2477	2477
2478	2478
2479	2479
2480	2480
2481	2481	HB1456 - 68 - LRB104 07779 KTG 17824 b
2482	2482
2483	2483
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2485	2485	HB1456 - 69 - LRB104 07779 KTG 17824 b
2486	2486	1 licensed by the Department of Human Services or to a licensed
2487	2487	2 hospital which provides substance abuse treatment services.
2488	2488	3 The Department of Healthcare and Family Services shall assure
2489	2489	4 coverage for the cost of treatment of the drug abuse or
2490	2490	5 addiction for pregnant recipients in accordance with the
2491	2491	6 Illinois Medicaid Program in conjunction with the Department
2492	2492	7 of Human Services.
2493	2493	8 All medical providers providing medical assistance to
2494	2494	9 pregnant individuals under this Code shall receive information
2495	2495	10 from the Department on the availability of services under any
2496	2496	11 program providing case management services for addicted
2497	2497	12 individuals, including information on appropriate referrals
2498	2498	13 for other social services that may be needed by addicted
2499	2499	14 individuals in addition to treatment for addiction.
2500	2500	15 The Illinois Department, in cooperation with the
2501	2501	16 Departments of Human Services (as successor to the Department
2502	2502	17 of Alcoholism and Substance Abuse) and Public Health, through
2503	2503	18 a public awareness campaign, may provide information
2504	2504	19 concerning treatment for alcoholism and drug abuse and
2505	2505	20 addiction, prenatal health care, and other pertinent programs
2506	2506	21 directed at reducing the number of drug-affected infants born
2507	2507	22 to recipients of medical assistance.
2508	2508	23 Neither the Department of Healthcare and Family Services
2509	2509	24 nor the Department of Human Services shall sanction the
2510	2510	25 recipient solely on the basis of the recipient's substance
2511	2511	26 abuse.
2512	2512
2513	2513
2514	2514
2515	2515
2516	2516
2517	2517	HB1456 - 69 - LRB104 07779 KTG 17824 b
2518	2518
2519	2519
2520	2520	HB1456- 70 -LRB104 07779 KTG 17824 b HB1456 - 70 - LRB104 07779 KTG 17824 b
2521	2521	HB1456 - 70 - LRB104 07779 KTG 17824 b
2522	2522	1 The Illinois Department shall establish such regulations
2523	2523	2 governing the dispensing of health services under this Article
2524	2524	3 as it shall deem appropriate. The Department should seek the
2525	2525	4 advice of formal professional advisory committees appointed by
2526	2526	5 the Director of the Illinois Department for the purpose of
2527	2527	6 providing regular advice on policy and administrative matters,
2528	2528	7 information dissemination and educational activities for
2529	2529	8 medical and health care providers, and consistency in
2530	2530	9 procedures to the Illinois Department.
2531	2531	10 The Illinois Department may develop and contract with
2532	2532	11 Partnerships of medical providers to arrange medical services
2533	2533	12 for persons eligible under Section 5-2 of this Code.
2534	2534	13 Implementation of this Section may be by demonstration
2535	2535	14 projects in certain geographic areas. The Partnership shall be
2536	2536	15 represented by a sponsor organization. The Department, by
2537	2537	16 rule, shall develop qualifications for sponsors of
2538	2538	17 Partnerships. Nothing in this Section shall be construed to
2539	2539	18 require that the sponsor organization be a medical
2540	2540	19 organization.
2541	2541	20 The sponsor must negotiate formal written contracts with
2542	2542	21 medical providers for physician services, inpatient and
2543	2543	22 outpatient hospital care, home health services, treatment for
2544	2544	23 alcoholism and substance abuse, and other services determined
2545	2545	24 necessary by the Illinois Department by rule for delivery by
2546	2546	25 Partnerships. Physician services must include prenatal and
2547	2547	26 obstetrical care. The Illinois Department shall reimburse
2548	2548
2549	2549
2550	2550
2551	2551
2552	2552
2553	2553	HB1456 - 70 - LRB104 07779 KTG 17824 b
2554	2554
2555	2555
2556	2556	HB1456- 71 -LRB104 07779 KTG 17824 b HB1456 - 71 - LRB104 07779 KTG 17824 b
2557	2557	HB1456 - 71 - LRB104 07779 KTG 17824 b
2558	2558	1 medical services delivered by Partnership providers to clients
2559	2559	2 in target areas according to provisions of this Article and
2560	2560	3 the Illinois Health Finance Reform Act, except that:
2561	2561	4 (1) Physicians participating in a Partnership and
2562	2562	5 providing certain services, which shall be determined by
2563	2563	6 the Illinois Department, to persons in areas covered by
2564	2564	7 the Partnership may receive an additional surcharge for
2565	2565	8 such services.
2566	2566	9 (2) The Department may elect to consider and negotiate
2567	2567	10 financial incentives to encourage the development of
2568	2568	11 Partnerships and the efficient delivery of medical care.
2569	2569	12 (3) Persons receiving medical services through
2570	2570	13 Partnerships may receive medical and case management
2571	2571	14 services above the level usually offered through the
2572	2572	15 medical assistance program.
2573	2573	16 Medical providers shall be required to meet certain
2574	2574	17 qualifications to participate in Partnerships to ensure the
2575	2575	18 delivery of high quality medical services. These
2576	2576	19 qualifications shall be determined by rule of the Illinois
2577	2577	20 Department and may be higher than qualifications for
2578	2578	21 participation in the medical assistance program. Partnership
2579	2579	22 sponsors may prescribe reasonable additional qualifications
2580	2580	23 for participation by medical providers, only with the prior
2581	2581	24 written approval of the Illinois Department.
2582	2582	25 Nothing in this Section shall limit the free choice of
2583	2583	26 practitioners, hospitals, and other providers of medical
2584	2584
2585	2585
2586	2586
2587	2587
2588	2588
2589	2589	HB1456 - 71 - LRB104 07779 KTG 17824 b
2590	2590
2591	2591
2592	2592	HB1456- 72 -LRB104 07779 KTG 17824 b HB1456 - 72 - LRB104 07779 KTG 17824 b
2593	2593	HB1456 - 72 - LRB104 07779 KTG 17824 b
2594	2594	1 services by clients. In order to ensure patient freedom of
2595	2595	2 choice, the Illinois Department shall immediately promulgate
2596	2596	3 all rules and take all other necessary actions so that
2597	2597	4 provided services may be accessed from therapeutically
2598	2598	5 certified optometrists to the full extent of the Illinois
2599	2599	6 Optometric Practice Act of 1987 without discriminating between
2600	2600	7 service providers.
2601	2601	8 The Department shall apply for a waiver from the United
2602	2602	9 States Health Care Financing Administration to allow for the
2603	2603	10 implementation of Partnerships under this Section.
2604	2604	11 The Illinois Department shall require health care
2605	2605	12 providers to maintain records that document the medical care
2606	2606	13 and services provided to recipients of Medical Assistance
2607	2607	14 under this Article. Such records must be retained for a period
2608	2608	15 of not less than 6 years from the date of service or as
2609	2609	16 provided by applicable State law, whichever period is longer,
2610	2610	17 except that if an audit is initiated within the required
2611	2611	18 retention period then the records must be retained until the
2612	2612	19 audit is completed and every exception is resolved. The
2613	2613	20 Illinois Department shall require health care providers to
2614	2614	21 make available, when authorized by the patient, in writing,
2615	2615	22 the medical records in a timely fashion to other health care
2616	2616	23 providers who are treating or serving persons eligible for
2617	2617	24 Medical Assistance under this Article. All dispensers of
2618	2618	25 medical services shall be required to maintain and retain
2619	2619	26 business and professional records sufficient to fully and
2620	2620
2621	2621
2622	2622
2623	2623
2624	2624
2625	2625	HB1456 - 72 - LRB104 07779 KTG 17824 b
2626	2626
2627	2627
2628	2628	HB1456- 73 -LRB104 07779 KTG 17824 b HB1456 - 73 - LRB104 07779 KTG 17824 b
2629	2629	HB1456 - 73 - LRB104 07779 KTG 17824 b
2630	2630	1 accurately document the nature, scope, details and receipt of
2631	2631	2 the health care provided to persons eligible for medical
2632	2632	3 assistance under this Code, in accordance with regulations
2633	2633	4 promulgated by the Illinois Department. The rules and
2634	2634	5 regulations shall require that proof of the receipt of
2635	2635	6 prescription drugs, dentures, prosthetic devices and
2636	2636	7 eyeglasses by eligible persons under this Section accompany
2637	2637	8 each claim for reimbursement submitted by the dispenser of
2638	2638	9 such medical services. No such claims for reimbursement shall
2639	2639	10 be approved for payment by the Illinois Department without
2640	2640	11 such proof of receipt, unless the Illinois Department shall
2641	2641	12 have put into effect and shall be operating a system of
2642	2642	13 post-payment audit and review which shall, on a sampling
2643	2643	14 basis, be deemed adequate by the Illinois Department to assure
2644	2644	15 that such drugs, dentures, prosthetic devices and eyeglasses
2645	2645	16 for which payment is being made are actually being received by
2646	2646	17 eligible recipients. Within 90 days after September 16, 1984
2647	2647	18 (the effective date of Public Act 83-1439), the Illinois
2648	2648	19 Department shall establish a current list of acquisition costs
2649	2649	20 for all prosthetic devices and any other items recognized as
2650	2650	21 medical equipment and supplies reimbursable under this Article
2651	2651	22 and shall update such list on a quarterly basis, except that
2652	2652	23 the acquisition costs of all prescription drugs shall be
2653	2653	24 updated no less frequently than every 30 days as required by
2654	2654	25 Section 5-5.12.
2655	2655	26 Notwithstanding any other law to the contrary, the
2656	2656
2657	2657
2658	2658
2659	2659
2660	2660
2661	2661	HB1456 - 73 - LRB104 07779 KTG 17824 b
2662	2662
2663	2663
2664	2664	HB1456- 74 -LRB104 07779 KTG 17824 b HB1456 - 74 - LRB104 07779 KTG 17824 b
2665	2665	HB1456 - 74 - LRB104 07779 KTG 17824 b
2666	2666	1 Illinois Department shall, within 365 days after July 22, 2013
2667	2667	2 (the effective date of Public Act 98-104), establish
2668	2668	3 procedures to permit skilled care facilities licensed under
2669	2669	4 the Nursing Home Care Act to submit monthly billing claims for
2670	2670	5 reimbursement purposes. Following development of these
2671	2671	6 procedures, the Department shall, by July 1, 2016, test the
2672	2672	7 viability of the new system and implement any necessary
2673	2673	8 operational or structural changes to its information
2674	2674	9 technology platforms in order to allow for the direct
2675	2675	10 acceptance and payment of nursing home claims.
2676	2676	11 Notwithstanding any other law to the contrary, the
2677	2677	12 Illinois Department shall, within 365 days after August 15,
2678	2678	13 2014 (the effective date of Public Act 98-963), establish
2679	2679	14 procedures to permit ID/DD facilities licensed under the ID/DD
2680	2680	15 Community Care Act and MC/DD facilities licensed under the
2681	2681	16 MC/DD Act to submit monthly billing claims for reimbursement
2682	2682	17 purposes. Following development of these procedures, the
2683	2683	18 Department shall have an additional 365 days to test the
2684	2684	19 viability of the new system and to ensure that any necessary
2685	2685	20 operational or structural changes to its information
2686	2686	21 technology platforms are implemented.
2687	2687	22 The Illinois Department shall require all dispensers of
2688	2688	23 medical services, other than an individual practitioner or
2689	2689	24 group of practitioners, desiring to participate in the Medical
2690	2690	25 Assistance program established under this Article to disclose
2691	2691	26 all financial, beneficial, ownership, equity, surety or other
2692	2692
2693	2693
2694	2694
2695	2695
2696	2696
2697	2697	HB1456 - 74 - LRB104 07779 KTG 17824 b
2698	2698
2699	2699
2700	2700	HB1456- 75 -LRB104 07779 KTG 17824 b HB1456 - 75 - LRB104 07779 KTG 17824 b
2701	2701	HB1456 - 75 - LRB104 07779 KTG 17824 b
2702	2702	1 interests in any and all firms, corporations, partnerships,
2703	2703	2 associations, business enterprises, joint ventures, agencies,
2704	2704	3 institutions or other legal entities providing any form of
2705	2705	4 health care services in this State under this Article.
2706	2706	5 The Illinois Department may require that all dispensers of
2707	2707	6 medical services desiring to participate in the medical
2708	2708	7 assistance program established under this Article disclose,
2709	2709	8 under such terms and conditions as the Illinois Department may
2710	2710	9 by rule establish, all inquiries from clients and attorneys
2711	2711	10 regarding medical bills paid by the Illinois Department, which
2712	2712	11 inquiries could indicate potential existence of claims or
2713	2713	12 liens for the Illinois Department.
2714	2714	13 Enrollment of a vendor shall be subject to a provisional
2715	2715	14 period and shall be conditional for one year. During the
2716	2716	15 period of conditional enrollment, the Department may terminate
2717	2717	16 the vendor's eligibility to participate in, or may disenroll
2718	2718	17 the vendor from, the medical assistance program without cause.
2719	2719	18 Unless otherwise specified, such termination of eligibility or
2720	2720	19 disenrollment is not subject to the Department's hearing
2721	2721	20 process. However, a disenrolled vendor may reapply without
2722	2722	21 penalty.
2723	2723	22 The Department has the discretion to limit the conditional
2724	2724	23 enrollment period for vendors based upon the category of risk
2725	2725	24 of the vendor.
2726	2726	25 Prior to enrollment and during the conditional enrollment
2727	2727	26 period in the medical assistance program, all vendors shall be
2728	2728
2729	2729
2730	2730
2731	2731
2732	2732
2733	2733	HB1456 - 75 - LRB104 07779 KTG 17824 b
2734	2734
2735	2735
2736	2736	HB1456- 76 -LRB104 07779 KTG 17824 b HB1456 - 76 - LRB104 07779 KTG 17824 b
2737	2737	HB1456 - 76 - LRB104 07779 KTG 17824 b
2738	2738	1 subject to enhanced oversight, screening, and review based on
2739	2739	2 the risk of fraud, waste, and abuse that is posed by the
2740	2740	3 category of risk of the vendor. The Illinois Department shall
2741	2741	4 establish the procedures for oversight, screening, and review,
2742	2742	5 which may include, but need not be limited to: criminal and
2743	2743	6 financial background checks; fingerprinting; license,
2744	2744	7 certification, and authorization verifications; unscheduled or
2745	2745	8 unannounced site visits; database checks; prepayment audit
2746	2746	9 reviews; audits; payment caps; payment suspensions; and other
2747	2747	10 screening as required by federal or State law.
2748	2748	11 The Department shall define or specify the following: (i)
2749	2749	12 by provider notice, the "category of risk of the vendor" for
2750	2750	13 each type of vendor, which shall take into account the level of
2751	2751	14 screening applicable to a particular category of vendor under
2752	2752	15 federal law and regulations; (ii) by rule or provider notice,
2753	2753	16 the maximum length of the conditional enrollment period for
2754	2754	17 each category of risk of the vendor; and (iii) by rule, the
2755	2755	18 hearing rights, if any, afforded to a vendor in each category
2756	2756	19 of risk of the vendor that is terminated or disenrolled during
2757	2757	20 the conditional enrollment period.
2758	2758	21 To be eligible for payment consideration, a vendor's
2759	2759	22 payment claim or bill, either as an initial claim or as a
2760	2760	23 resubmitted claim following prior rejection, must be received
2761	2761	24 by the Illinois Department, or its fiscal intermediary, no
2762	2762	25 later than 180 days after the latest date on the claim on which
2763	2763	26 medical goods or services were provided, with the following
2764	2764
2765	2765
2766	2766
2767	2767
2768	2768
2769	2769	HB1456 - 76 - LRB104 07779 KTG 17824 b
2770	2770
2771	2771
2772	2772	HB1456- 77 -LRB104 07779 KTG 17824 b HB1456 - 77 - LRB104 07779 KTG 17824 b
2773	2773	HB1456 - 77 - LRB104 07779 KTG 17824 b
2774	2774	1 exceptions:
2775	2775	2 (1) In the case of a provider whose enrollment is in
2776	2776	3 process by the Illinois Department, the 180-day period
2777	2777	4 shall not begin until the date on the written notice from
2778	2778	5 the Illinois Department that the provider enrollment is
2779	2779	6 complete.
2780	2780	7 (2) In the case of errors attributable to the Illinois
2781	2781	8 Department or any of its claims processing intermediaries
2782	2782	9 which result in an inability to receive, process, or
2783	2783	10 adjudicate a claim, the 180-day period shall not begin
2784	2784	11 until the provider has been notified of the error.
2785	2785	12 (3) In the case of a provider for whom the Illinois
2786	2786	13 Department initiates the monthly billing process.
2787	2787	14 (4) In the case of a provider operated by a unit of
2788	2788	15 local government with a population exceeding 3,000,000
2789	2789	16 when local government funds finance federal participation
2790	2790	17 for claims payments.
2791	2791	18 For claims for services rendered during a period for which
2792	2792	19 a recipient received retroactive eligibility, claims must be
2793	2793	20 filed within 180 days after the Department determines the
2794	2794	21 applicant is eligible. For claims for which the Illinois
2795	2795	22 Department is not the primary payer, claims must be submitted
2796	2796	23 to the Illinois Department within 180 days after the final
2797	2797	24 adjudication by the primary payer.
2798	2798	25 In the case of long term care facilities, within 120
2799	2799	26 calendar days of receipt by the facility of required
2800	2800
2801	2801
2802	2802
2803	2803
2804	2804
2805	2805	HB1456 - 77 - LRB104 07779 KTG 17824 b
2806	2806
2807	2807
2808	2808	HB1456- 78 -LRB104 07779 KTG 17824 b HB1456 - 78 - LRB104 07779 KTG 17824 b
2809	2809	HB1456 - 78 - LRB104 07779 KTG 17824 b
2810	2810	1 prescreening information, new admissions with associated
2811	2811	2 admission documents shall be submitted through the Medical
2812	2812	3 Electronic Data Interchange (MEDI) or the Recipient
2813	2813	4 Eligibility Verification (REV) System or shall be submitted
2814	2814	5 directly to the Department of Human Services using required
2815	2815	6 admission forms. Effective September 1, 2014, admission
2816	2816	7 documents, including all prescreening information, must be
2817	2817	8 submitted through MEDI or REV. Confirmation numbers assigned
2818	2818	9 to an accepted transaction shall be retained by a facility to
2819	2819	10 verify timely submittal. Once an admission transaction has
2820	2820	11 been completed, all resubmitted claims following prior
2821	2821	12 rejection are subject to receipt no later than 180 days after
2822	2822	13 the admission transaction has been completed.
2823	2823	14 Claims that are not submitted and received in compliance
2824	2824	15 with the foregoing requirements shall not be eligible for
2825	2825	16 payment under the medical assistance program, and the State
2826	2826	17 shall have no liability for payment of those claims.
2827	2827	18 To the extent consistent with applicable information and
2828	2828	19 privacy, security, and disclosure laws, State and federal
2829	2829	20 agencies and departments shall provide the Illinois Department
2830	2830	21 access to confidential and other information and data
2831	2831	22 necessary to perform eligibility and payment verifications and
2832	2832	23 other Illinois Department functions. This includes, but is not
2833	2833	24 limited to: information pertaining to licensure;
2834	2834	25 certification; earnings; immigration status; citizenship; wage
2835	2835	26 reporting; unearned and earned income; pension income;
2836	2836
2837	2837
2838	2838
2839	2839
2840	2840
2841	2841	HB1456 - 78 - LRB104 07779 KTG 17824 b
2842	2842
2843	2843
2844	2844	HB1456- 79 -LRB104 07779 KTG 17824 b HB1456 - 79 - LRB104 07779 KTG 17824 b
2845	2845	HB1456 - 79 - LRB104 07779 KTG 17824 b
2846	2846	1 employment; supplemental security income; social security
2847	2847	2 numbers; National Provider Identifier (NPI) numbers; the
2848	2848	3 National Practitioner Data Bank (NPDB); program and agency
2849	2849	4 exclusions; taxpayer identification numbers; tax delinquency;
2850	2850	5 corporate information; and death records.
2851	2851	6 The Illinois Department shall enter into agreements with
2852	2852	7 State agencies and departments, and is authorized to enter
2853	2853	8 into agreements with federal agencies and departments, under
2854	2854	9 which such agencies and departments shall share data necessary
2855	2855	10 for medical assistance program integrity functions and
2856	2856	11 oversight. The Illinois Department shall develop, in
2857	2857	12 cooperation with other State departments and agencies, and in
2858	2858	13 compliance with applicable federal laws and regulations,
2859	2859	14 appropriate and effective methods to share such data. At a
2860	2860	15 minimum, and to the extent necessary to provide data sharing,
2861	2861	16 the Illinois Department shall enter into agreements with State
2862	2862	17 agencies and departments, and is authorized to enter into
2863	2863	18 agreements with federal agencies and departments, including,
2864	2864	19 but not limited to: the Secretary of State; the Department of
2865	2865	20 Revenue; the Department of Public Health; the Department of
2866	2866	21 Human Services; and the Department of Financial and
2867	2867	22 Professional Regulation.
2868	2868	23 Beginning in fiscal year 2013, the Illinois Department
2869	2869	24 shall set forth a request for information to identify the
2870	2870	25 benefits of a pre-payment, post-adjudication, and post-edit
2871	2871	26 claims system with the goals of streamlining claims processing
2872	2872
2873	2873
2874	2874
2875	2875
2876	2876
2877	2877	HB1456 - 79 - LRB104 07779 KTG 17824 b
2878	2878
2879	2879
2880	2880	HB1456- 80 -LRB104 07779 KTG 17824 b HB1456 - 80 - LRB104 07779 KTG 17824 b
2881	2881	HB1456 - 80 - LRB104 07779 KTG 17824 b
2882	2882	1 and provider reimbursement, reducing the number of pending or
2883	2883	2 rejected claims, and helping to ensure a more transparent
2884	2884	3 adjudication process through the utilization of: (i) provider
2885	2885	4 data verification and provider screening technology; and (ii)
2886	2886	5 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
2887	2887	6 post-adjudicated predictive modeling with an integrated case
2888	2888	7 management system with link analysis. Such a request for
2889	2889	8 information shall not be considered as a request for proposal
2890	2890	9 or as an obligation on the part of the Illinois Department to
2891	2891	10 take any action or acquire any products or services.
2892	2892	11 The Illinois Department shall establish policies,
2893	2893	12 procedures, standards and criteria by rule for the
2894	2894	13 acquisition, repair and replacement of orthotic and prosthetic
2895	2895	14 devices and durable medical equipment. Such rules shall
2896	2896	15 provide, but not be limited to, the following services: (1)
2897	2897	16 immediate repair or replacement of such devices by recipients;
2898	2898	17 and (2) rental, lease, purchase or lease-purchase of durable
2899	2899	18 medical equipment in a cost-effective manner, taking into
2900	2900	19 consideration the recipient's medical prognosis, the extent of
2901	2901	20 the recipient's needs, and the requirements and costs for
2902	2902	21 maintaining such equipment. Subject to prior approval, such
2903	2903	22 rules shall enable a recipient to temporarily acquire and use
2904	2904	23 alternative or substitute devices or equipment pending repairs
2905	2905	24 or replacements of any device or equipment previously
2906	2906	25 authorized for such recipient by the Department.
2907	2907	26 Notwithstanding any provision of Section 5-5f to the contrary,
2908	2908
2909	2909
2910	2910
2911	2911
2912	2912
2913	2913	HB1456 - 80 - LRB104 07779 KTG 17824 b
2914	2914
2915	2915
2916	2916	HB1456- 81 -LRB104 07779 KTG 17824 b HB1456 - 81 - LRB104 07779 KTG 17824 b
2917	2917	HB1456 - 81 - LRB104 07779 KTG 17824 b
2918	2918	1 the Department may, by rule, exempt certain replacement
2919	2919	2 wheelchair parts from prior approval and, for wheelchairs,
2920	2920	3 wheelchair parts, wheelchair accessories, and related seating
2921	2921	4 and positioning items, determine the wholesale price by
2922	2922	5 methods other than actual acquisition costs.
2923	2923	6 The Department shall require, by rule, all providers of
2924	2924	7 durable medical equipment to be accredited by an accreditation
2925	2925	8 organization approved by the federal Centers for Medicare and
2926	2926	9 Medicaid Services and recognized by the Department in order to
2927	2927	10 bill the Department for providing durable medical equipment to
2928	2928	11 recipients. No later than 15 months after the effective date
2929	2929	12 of the rule adopted pursuant to this paragraph, all providers
2930	2930	13 must meet the accreditation requirement.
2931	2931	14 In order to promote environmental responsibility, meet the
2932	2932	15 needs of recipients and enrollees, and achieve significant
2933	2933	16 cost savings, the Department, or a managed care organization
2934	2934	17 under contract with the Department, may provide recipients or
2935	2935	18 managed care enrollees who have a prescription or Certificate
2936	2936	19 of Medical Necessity access to refurbished durable medical
2937	2937	20 equipment under this Section (excluding prosthetic and
2938	2938	21 orthotic devices as defined in the Orthotics, Prosthetics, and
2939	2939	22 Pedorthics Practice Act and complex rehabilitation technology
2940	2940	23 products and associated services) through the State's
2941	2941	24 assistive technology program's reutilization program, using
2942	2942	25 staff with the Assistive Technology Professional (ATP)
2943	2943	26 Certification if the refurbished durable medical equipment:
2944	2944
2945	2945
2946	2946
2947	2947
2948	2948
2949	2949	HB1456 - 81 - LRB104 07779 KTG 17824 b
2950	2950
2951	2951
2952	2952	HB1456- 82 -LRB104 07779 KTG 17824 b HB1456 - 82 - LRB104 07779 KTG 17824 b
2953	2953	HB1456 - 82 - LRB104 07779 KTG 17824 b
2954	2954	1 (i) is available; (ii) is less expensive, including shipping
2955	2955	2 costs, than new durable medical equipment of the same type;
2956	2956	3 (iii) is able to withstand at least 3 years of use; (iv) is
2957	2957	4 cleaned, disinfected, sterilized, and safe in accordance with
2958	2958	5 federal Food and Drug Administration regulations and guidance
2959	2959	6 governing the reprocessing of medical devices in health care
2960	2960	7 settings; and (v) equally meets the needs of the recipient or
2961	2961	8 enrollee. The reutilization program shall confirm that the
2962	2962	9 recipient or enrollee is not already in receipt of the same or
2963	2963	10 similar equipment from another service provider, and that the
2964	2964	11 refurbished durable medical equipment equally meets the needs
2965	2965	12 of the recipient or enrollee. Nothing in this paragraph shall
2966	2966	13 be construed to limit recipient or enrollee choice to obtain
2967	2967	14 new durable medical equipment or place any additional prior
2968	2968	15 authorization conditions on enrollees of managed care
2969	2969	16 organizations.
2970	2970	17 The Department shall execute, relative to the nursing home
2971	2971	18 prescreening project, written inter-agency agreements with the
2972	2972	19 Department of Human Services and the Department on Aging, to
2973	2973	20 effect the following: (i) intake procedures and common
2974	2974	21 eligibility criteria for those persons who are receiving
2975	2975	22 non-institutional services; and (ii) the establishment and
2976	2976	23 development of non-institutional services in areas of the
2977	2977	24 State where they are not currently available or are
2978	2978	25 undeveloped; and (iii) notwithstanding any other provision of
2979	2979	26 law, subject to federal approval, on and after July 1, 2012, an
2980	2980
2981	2981
2982	2982
2983	2983
2984	2984
2985	2985	HB1456 - 82 - LRB104 07779 KTG 17824 b
2986	2986
2987	2987
2988	2988	HB1456- 83 -LRB104 07779 KTG 17824 b HB1456 - 83 - LRB104 07779 KTG 17824 b
2989	2989	HB1456 - 83 - LRB104 07779 KTG 17824 b
2990	2990	1 increase in the determination of need (DON) scores from 29 to
2991	2991	2 37 for applicants for institutional and home and
2992	2992	3 community-based long term care; if and only if federal
2993	2993	4 approval is not granted, the Department may, in conjunction
2994	2994	5 with other affected agencies, implement utilization controls
2995	2995	6 or changes in benefit packages to effectuate a similar savings
2996	2996	7 amount for this population; and (iv) no later than July 1,
2997	2997	8 2013, minimum level of care eligibility criteria for
2998	2998	9 institutional and home and community-based long term care; and
2999	2999	10 (v) no later than October 1, 2013, establish procedures to
3000	3000	11 permit long term care providers access to eligibility scores
3001	3001	12 for individuals with an admission date who are seeking or
3002	3002	13 receiving services from the long term care provider. In order
3003	3003	14 to select the minimum level of care eligibility criteria, the
3004	3004	15 Governor shall establish a workgroup that includes affected
3005	3005	16 agency representatives and stakeholders representing the
3006	3006	17 institutional and home and community-based long term care
3007	3007	18 interests. This Section shall not restrict the Department from
3008	3008	19 implementing lower level of care eligibility criteria for
3009	3009	20 community-based services in circumstances where federal
3010	3010	21 approval has been granted.
3011	3011	22 The Illinois Department shall develop and operate, in
3012	3012	23 cooperation with other State Departments and agencies and in
3013	3013	24 compliance with applicable federal laws and regulations,
3014	3014	25 appropriate and effective systems of health care evaluation
3015	3015	26 and programs for monitoring of utilization of health care
3016	3016
3017	3017
3018	3018
3019	3019
3020	3020
3021	3021	HB1456 - 83 - LRB104 07779 KTG 17824 b
3022	3022
3023	3023
3024	3024	HB1456- 84 -LRB104 07779 KTG 17824 b HB1456 - 84 - LRB104 07779 KTG 17824 b
3025	3025	HB1456 - 84 - LRB104 07779 KTG 17824 b
3026	3026	1 services and facilities, as it affects persons eligible for
3027	3027	2 medical assistance under this Code.
3028	3028	3 The Illinois Department shall report annually to the
3029	3029	4 General Assembly, no later than the second Friday in April of
3030	3030	5 1979 and each year thereafter, in regard to:
3031	3031	6 (a) actual statistics and trends in utilization of
3032	3032	7 medical services by public aid recipients;
3033	3033	8 (b) actual statistics and trends in the provision of
3034	3034	9 the various medical services by medical vendors;
3035	3035	10 (c) current rate structures and proposed changes in
3036	3036	11 those rate structures for the various medical vendors; and
3037	3037	12 (d) efforts at utilization review and control by the
3038	3038	13 Illinois Department.
3039	3039	14 The period covered by each report shall be the 3 years
3040	3040	15 ending on the June 30 prior to the report. The report shall
3041	3041	16 include suggested legislation for consideration by the General
3042	3042	17 Assembly. The requirement for reporting to the General
3043	3043	18 Assembly shall be satisfied by filing copies of the report as
3044	3044	19 required by Section 3.1 of the General Assembly Organization
3045	3045	20 Act, and filing such additional copies with the State
3046	3046	21 Government Report Distribution Center for the General Assembly
3047	3047	22 as is required under paragraph (t) of Section 7 of the State
3048	3048	23 Library Act.
3049	3049	24 Rulemaking authority to implement Public Act 95-1045, if
3050	3050	25 any, is conditioned on the rules being adopted in accordance
3051	3051	26 with all provisions of the Illinois Administrative Procedure
3052	3052
3053	3053
3054	3054
3055	3055
3056	3056
3057	3057	HB1456 - 84 - LRB104 07779 KTG 17824 b
3058	3058
3059	3059
3060	3060	HB1456- 85 -LRB104 07779 KTG 17824 b HB1456 - 85 - LRB104 07779 KTG 17824 b
3061	3061	HB1456 - 85 - LRB104 07779 KTG 17824 b
3062	3062	1 Act and all rules and procedures of the Joint Committee on
3063	3063	2 Administrative Rules; any purported rule not so adopted, for
3064	3064	3 whatever reason, is unauthorized.
3065	3065	4 On and after July 1, 2012, the Department shall reduce any
3066	3066	5 rate of reimbursement for services or other payments or alter
3067	3067	6 any methodologies authorized by this Code to reduce any rate
3068	3068	7 of reimbursement for services or other payments in accordance
3069	3069	8 with Section 5-5e.
3070	3070	9 Because kidney transplantation can be an appropriate,
3071	3071	10 cost-effective alternative to renal dialysis when medically
3072	3072	11 necessary and notwithstanding the provisions of Section 1-11
3073	3073	12 of this Code, beginning October 1, 2014, the Department shall
3074	3074	13 cover kidney transplantation for noncitizens with end-stage
3075	3075	14 renal disease who are not eligible for comprehensive medical
3076	3076	15 benefits, who meet the residency requirements of Section 5-3
3077	3077	16 of this Code, and who would otherwise meet the financial
3078	3078	17 requirements of the appropriate class of eligible persons
3079	3079	18 under Section 5-2 of this Code. To qualify for coverage of
3080	3080	19 kidney transplantation, such person must be receiving
3081	3081	20 emergency renal dialysis services covered by the Department.
3082	3082	21 Providers under this Section shall be prior approved and
3083	3083	22 certified by the Department to perform kidney transplantation
3084	3084	23 and the services under this Section shall be limited to
3085	3085	24 services associated with kidney transplantation.
3086	3086	25 Notwithstanding any other provision of this Code to the
3087	3087	26 contrary, on or after July 1, 2015, all FDA-approved FDA
3088	3088
3089	3089
3090	3090
3091	3091
3092	3092
3093	3093	HB1456 - 85 - LRB104 07779 KTG 17824 b
3094	3094
3095	3095
3096	3096	HB1456- 86 -LRB104 07779 KTG 17824 b HB1456 - 86 - LRB104 07779 KTG 17824 b
3097	3097	HB1456 - 86 - LRB104 07779 KTG 17824 b
3098	3098	1 approved forms of medication assisted treatment prescribed for
3099	3099	2 the treatment of alcohol dependence or treatment of opioid
3100	3100	3 dependence shall be covered under both fee-for-service and
3101	3101	4 managed care medical assistance programs for persons who are
3102	3102	5 otherwise eligible for medical assistance under this Article
3103	3103	6 and shall not be subject to any (1) utilization control, other
3104	3104	7 than those established under the American Society of Addiction
3105	3105	8 Medicine patient placement criteria, (2) prior authorization
3106	3106	9 mandate, (3) lifetime restriction limit mandate, or (4)
3107	3107	10 limitations on dosage.
3108	3108	11 On or after July 1, 2015, opioid antagonists prescribed
3109	3109	12 for the treatment of an opioid overdose, including the
3110	3110	13 medication product, administration devices, and any pharmacy
3111	3111	14 fees or hospital fees related to the dispensing, distribution,
3112	3112	15 and administration of the opioid antagonist, shall be covered
3113	3113	16 under the medical assistance program for persons who are
3114	3114	17 otherwise eligible for medical assistance under this Article.
3115	3115	18 As used in this Section, "opioid antagonist" means a drug that
3116	3116	19 binds to opioid receptors and blocks or inhibits the effect of
3117	3117	20 opioids acting on those receptors, including, but not limited
3118	3118	21 to, naloxone hydrochloride or any other similarly acting drug
3119	3119	22 approved by the U.S. Food and Drug Administration. The
3120	3120	23 Department shall not impose a copayment on the coverage
3121	3121	24 provided for naloxone hydrochloride under the medical
3122	3122	25 assistance program.
3123	3123	26 Upon federal approval, the Department shall provide
3124	3124
3125	3125
3126	3126
3127	3127
3128	3128
3129	3129	HB1456 - 86 - LRB104 07779 KTG 17824 b
3130	3130
3131	3131
3132	3132	HB1456- 87 -LRB104 07779 KTG 17824 b HB1456 - 87 - LRB104 07779 KTG 17824 b
3133	3133	HB1456 - 87 - LRB104 07779 KTG 17824 b
3134	3134	1 coverage and reimbursement for all drugs that are approved for
3135	3135	2 marketing by the federal Food and Drug Administration and that
3136	3136	3 are recommended by the federal Public Health Service or the
3137	3137	4 United States Centers for Disease Control and Prevention for
3138	3138	5 pre-exposure prophylaxis and related pre-exposure prophylaxis
3139	3139	6 services, including, but not limited to, HIV and sexually
3140	3140	7 transmitted infection screening, treatment for sexually
3141	3141	8 transmitted infections, medical monitoring, assorted labs, and
3142	3142	9 counseling to reduce the likelihood of HIV infection among
3143	3143	10 individuals who are not infected with HIV but who are at high
3144	3144	11 risk of HIV infection.
3145	3145	12 A federally qualified health center, as defined in Section
3146	3146	13 1905(l)(2)(B) of the federal Social Security Act, shall be
3147	3147	14 reimbursed by the Department in accordance with the federally
3148	3148	15 qualified health center's encounter rate for services provided
3149	3149	16 to medical assistance recipients that are performed by a
3150	3150	17 dental hygienist, as defined under the Illinois Dental
3151	3151	18 Practice Act, working under the general supervision of a
3152	3152	19 dentist and employed by a federally qualified health center.
3153	3153	20 Within 90 days after October 8, 2021 (the effective date
3154	3154	21 of Public Act 102-665), the Department shall seek federal
3155	3155	22 approval of a State Plan amendment to expand coverage for
3156	3156	23 family planning services that includes presumptive eligibility
3157	3157	24 to individuals whose income is at or below 208% of the federal
3158	3158	25 poverty level. Coverage under this Section shall be effective
3159	3159	26 beginning no later than December 1, 2022.
3160	3160
3161	3161
3162	3162
3163	3163
3164	3164
3165	3165	HB1456 - 87 - LRB104 07779 KTG 17824 b
3166	3166
3167	3167
3168	3168	HB1456- 88 -LRB104 07779 KTG 17824 b HB1456 - 88 - LRB104 07779 KTG 17824 b
3169	3169	HB1456 - 88 - LRB104 07779 KTG 17824 b
3170	3170	1 Subject to approval by the federal Centers for Medicare
3171	3171	2 and Medicaid Services of a Title XIX State Plan amendment
3172	3172	3 electing the Program of All-Inclusive Care for the Elderly
3173	3173	4 (PACE) as a State Medicaid option, as provided for by Subtitle
3174	3174	5 I (commencing with Section 4801) of Title IV of the Balanced
3175	3175	6 Budget Act of 1997 (Public Law 105-33) and Part 460
3176	3176	7 (commencing with Section 460.2) of Subchapter E of Title 42 of
3177	3177	8 the Code of Federal Regulations, PACE program services shall
3178	3178	9 become a covered benefit of the medical assistance program,
3179	3179	10 subject to criteria established in accordance with all
3180	3180	11 applicable laws.
3181	3181	12 Notwithstanding any other provision of this Code,
3182	3182	13 community-based pediatric palliative care from a trained
3183	3183	14 interdisciplinary team shall be covered under the medical
3184	3184	15 assistance program as provided in Section 15 of the Pediatric
3185	3185	16 Palliative Care Act.
3186	3186	17 Notwithstanding any other provision of this Code, within
3187	3187	18 12 months after June 2, 2022 (the effective date of Public Act
3188	3188	19 102-1037) and subject to federal approval, acupuncture
3189	3189	20 services performed by an acupuncturist licensed under the
3190	3190	21 Acupuncture Practice Act who is acting within the scope of his
3191	3191	22 or her license shall be covered under the medical assistance
3192	3192	23 program. The Department shall apply for any federal waiver or
3193	3193	24 State Plan amendment, if required, to implement this
3194	3194	25 paragraph. The Department may adopt any rules, including
3195	3195	26 standards and criteria, necessary to implement this paragraph.
3196	3196
3197	3197
3198	3198
3199	3199
3200	3200
3201	3201	HB1456 - 88 - LRB104 07779 KTG 17824 b
3202	3202
3203	3203
3204	3204	HB1456- 89 -LRB104 07779 KTG 17824 b HB1456 - 89 - LRB104 07779 KTG 17824 b
3205	3205	HB1456 - 89 - LRB104 07779 KTG 17824 b
3206	3206	1 Notwithstanding any other provision of this Code, the
3207	3207	2 medical assistance program shall, subject to federal approval,
3208	3208	3 reimburse hospitals for costs associated with a newborn
3209	3209	4 screening test for the presence of metachromatic
3210	3210	5 leukodystrophy, as required under the Newborn Metabolic
3211	3211	6 Screening Act, at a rate not less than the fee charged by the
3212	3212	7 Department of Public Health. Notwithstanding any other
3213	3213	8 provision of this Code, the medical assistance program shall,
3214	3214	9 subject to appropriation and federal approval, also reimburse
3215	3215	10 hospitals for costs associated with all newborn screening
3216	3216	11 tests added on and after August 9, 2024 (the effective date of
3217	3217	12 Public Act 103-909) this amendatory Act of the 103rd General
3218	3218	13 Assembly to the Newborn Metabolic Screening Act and required
3219	3219	14 to be performed under that Act at a rate not less than the fee
3220	3220	15 charged by the Department of Public Health. The Department
3221	3221	16 shall seek federal approval before the implementation of the
3222	3222	17 newborn screening test fees by the Department of Public
3223	3223	18 Health.
3224	3224	19 Notwithstanding any other provision of this Code,
3225	3225	20 beginning on January 1, 2024, subject to federal approval,
3226	3226	21 cognitive assessment and care planning services provided to a
3227	3227	22 person who experiences signs or symptoms of cognitive
3228	3228	23 impairment, as defined by the Diagnostic and Statistical
3229	3229	24 Manual of Mental Disorders, Fifth Edition, shall be covered
3230	3230	25 under the medical assistance program for persons who are
3231	3231	26 otherwise eligible for medical assistance under this Article.
3232	3232
3233	3233
3234	3234
3235	3235
3236	3236
3237	3237	HB1456 - 89 - LRB104 07779 KTG 17824 b
3238	3238
3239	3239
3240	3240	HB1456- 90 -LRB104 07779 KTG 17824 b HB1456 - 90 - LRB104 07779 KTG 17824 b
3241	3241	HB1456 - 90 - LRB104 07779 KTG 17824 b
3242	3242	1 Notwithstanding any other provision of this Code,
3243	3243	2 medically necessary reconstructive services that are intended
3244	3244	3 to restore physical appearance shall be covered under the
3245	3245	4 medical assistance program for persons who are otherwise
3246	3246	5 eligible for medical assistance under this Article. As used in
3247	3247	6 this paragraph, "reconstructive services" means treatments
3248	3248	7 performed on structures of the body damaged by trauma to
3249	3249	8 restore physical appearance.
3250	3250	9 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
3251	3251	10 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
3252	3252	11 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
3253	3253	12 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
3254	3254	13 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
3255	3255	14 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
3256	3256	15 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
3257	3257	16 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
3258	3258	17 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
3259	3259	18 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
3260	3260	19 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
3261	3261	20 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
3262	3262	21 8-9-24; revised 10-10-24.)
3263	3263	22 (305 ILCS 5/12-4.35)
3264	3264	23 Sec. 12-4.35. Medical services for certain noncitizens.
3265	3265	24 (a) Notwithstanding Section 1-11 of this Code or Section 20(a)
3266	3266	25 of the Children's Health Insurance Program Act, the Department
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3277	3277	1 of Healthcare and Family Services may provide medical services
3278	3278	2 to noncitizens who have not yet attained 19 years of age and
3279	3279	3 who are not eligible for medical assistance under Article V of
3280	3280	4 this Code or under the Children's Health Insurance Program
3281	3281	5 created by the Children's Health Insurance Program Act due to
3282	3282	6 their not meeting the otherwise applicable provisions of
3283	3283	7 Section 1-11 of this Code or Section 20(a) of the Children's
3284	3284	8 Health Insurance Program Act. The medical services available,
3285	3285	9 standards for eligibility, and other conditions of
3286	3286	10 participation under this Section shall be established by rule
3287	3287	11 by the Department; however, any such rule shall be at least as
3288	3288	12 restrictive as the rules for medical assistance under Article
3289	3289	13 V of this Code or the Children's Health Insurance Program
3290	3290	14 created by the Children's Health Insurance Program Act.
3291	3291	15 (a-5) Notwithstanding Section 1-11 of this Code, the
3292	3292	16 Department of Healthcare and Family Services may provide
3293	3293	17 medical assistance in accordance with Article V of this Code
3294	3294	18 to noncitizens over the age of 65 years of age who are not
3295	3295	19 eligible for medical assistance under Article V of this Code
3296	3296	20 due to their not meeting the otherwise applicable provisions
3297	3297	21 of Section 1-11 of this Code, whose income is at or below 100%
3298	3298	22 of the federal poverty level after deducting the costs of
3299	3299	23 medical or other remedial care, and who would otherwise meet
3300	3300	24 the eligibility requirements in Section 5-2 of this Code. The
3301	3301	25 medical services available, standards for eligibility, and
3302	3302	26 other conditions of participation under this Section shall be
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3313	3313	1 established by rule by the Department; however, any such rule
3314	3314	2 shall be at least as restrictive as the rules for medical
3315	3315	3 assistance under Article V of this Code.
3316	3316	4 (a-6) By May 30, 2022, notwithstanding Section 1-11 of
3317	3317	5 this Code, the Department of Healthcare and Family Services
3318	3318	6 may provide medical services to noncitizens 55 years of age
3319	3319	7 through 64 years of age who (i) are not eligible for medical
3320	3320	8 assistance under Article V of this Code due to their not
3321	3321	9 meeting the otherwise applicable provisions of Section 1-11 of
3322	3322	10 this Code and (ii) have income at or below 133% of the federal
3323	3323	11 poverty level plus 5% for the applicable family size as
3324	3324	12 determined under applicable federal law and regulations.
3325	3325	13 Persons eligible for medical services under Public Act 102-16
3326	3326	14 shall receive benefits identical to the benefits provided
3327	3327	15 under the Health Benefits Service Package as that term is
3328	3328	16 defined in subsection (m) of Section 5-1.1 of this Code.
3329	3329	17 (a-7) By July 1, 2022, notwithstanding Section 1-11 of
3330	3330	18 this Code, the Department of Healthcare and Family Services
3331	3331	19 may provide medical services to noncitizens 42 years of age
3332	3332	20 through 54 years of age who (i) are not eligible for medical
3333	3333	21 assistance under Article V of this Code due to their not
3334	3334	22 meeting the otherwise applicable provisions of Section 1-11 of
3335	3335	23 this Code and (ii) have income at or below 133% of the federal
3336	3336	24 poverty level plus 5% for the applicable family size as
3337	3337	25 determined under applicable federal law and regulations. The
3338	3338	26 medical services available, standards for eligibility, and
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3349	3349	1 other conditions of participation under this Section shall be
3350	3350	2 established by rule by the Department; however, any such rule
3351	3351	3 shall be at least as restrictive as the rules for medical
3352	3352	4 assistance under Article V of this Code. In order to provide
3353	3353	5 for the timely and expeditious implementation of this
3354	3354	6 subsection, the Department may adopt rules necessary to
3355	3355	7 establish and implement this subsection through the use of
3356	3356	8 emergency rulemaking in accordance with Section 5-45 of the
3357	3357	9 Illinois Administrative Procedure Act. For purposes of the
3358	3358	10 Illinois Administrative Procedure Act, the General Assembly
3359	3359	11 finds that the adoption of rules to implement this subsection
3360	3360	12 is deemed necessary for the public interest, safety, and
3361	3361	13 welfare.
3362	3362	14 (a-10) Notwithstanding the provisions of Section 1-11, the
3363	3363	15 Department shall cover immunosuppressive drugs and related
3364	3364	16 services associated with post-kidney transplant management,
3365	3365	17 excluding long-term care costs, for noncitizens who: (i) are
3366	3366	18 not eligible for comprehensive medical benefits; (ii) meet the
3367	3367	19 residency requirements of Section 5-3; and (iii) would meet
3368	3368	20 the financial eligibility requirements of Section 5-2.
3369	3369	21 (b) The Department is authorized to take any action that
3370	3370	22 would not otherwise be prohibited by applicable law,
3371	3371	23 including, without limitation, cessation or limitation of
3372	3372	24 enrollment, reduction of available medical services, and
3373	3373	25 changing standards for eligibility, that is deemed necessary
3374	3374	26 by the Department during a State fiscal year to assure that
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3385	3385	1 payments under this Section do not exceed available funds.
3386	3386	2 (c) (Blank).
3387	3387	3 (d) (Blank).
3388	3388	4 (e) In order to provide for the expeditious and effective
3389	3389	5 ongoing implementation of this Section, the Department may
3390	3390	6 adopt rules through the use of emergency rulemaking in
3391	3391	7 accordance with Section 5-45 of the Illinois Administrative
3392	3392	8 Procedure Act, except that the limitation on the number of
3393	3393	9 emergency rules that may be adopted in a 24-month period shall
3394	3394	10 not apply. For purposes of the Illinois Administrative
3395	3395	11 Procedure Act, the General Assembly finds that the adoption of
3396	3396	12 rules to implement this Section is deemed necessary for the
3397	3397	13 public interest, safety, and welfare. This subsection (e) is
3398	3398	14 inoperative on and after July 1, 2025.
3399	3399	15 (Source: P.A. 102-16, eff. 6-17-21; 102-43, Article 25,
3400	3400	16 Section 25-15, eff. 7-6-21; 102-43, Article 45, Section 45-5,
3401	3401	17 eff. 7-6-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22;
3402	3402	18 103-102, eff. 6-16-23.)
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