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
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
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.
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LRB104 07779 KTG 17824 b
A BILL FOR
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HB1456 LRB104 07779 KTG 17824 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 (5 ILCS 100/5-45.37 rep.)
5 Section 5. The Illinois Administrative Procedure Act is
6 amended by repealing Section 5-45.37.
7 Section 10. The Illinois Public Aid Code is amended by
8 changing Sections 5-2, 5-5, and 12-4.35 as follows:
9 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
10 Sec. 5-2. Classes of persons eligible. Medical assistance
11 under this Article shall be available to any of the following
12 classes of persons in respect to whom a plan for coverage has
13 been submitted to the Governor by the Illinois Department and
14 approved by him. If changes made in this Section 5-2 require
15 federal approval, they shall not take effect until such
16 approval has been received:
17 1. Recipients of basic maintenance grants under
18 Articles III and IV.
19 2. Beginning January 1, 2014, persons otherwise
20 eligible for basic maintenance under Article III,
21 excluding any eligibility requirements that are
22 inconsistent with any federal law or federal regulation,
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
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.
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A BILL FOR
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
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1 as interpreted by the U.S. Department of Health and Human
2 Services, but who fail to qualify thereunder on the basis
3 of need, and who have insufficient income and resources to
4 meet the costs of necessary medical care, including, but
5 not limited to, the following:
6 (a) All persons otherwise eligible for basic
7 maintenance under Article III but who fail to qualify
8 under that Article on the basis of need and who meet
9 either of the following requirements:
10 (i) their income, as determined by the
11 Illinois Department in accordance with any federal
12 requirements, is equal to or less than 100% of the
13 federal poverty level; or
14 (ii) their income, after the deduction of
15 costs incurred for medical care and for other
16 types of remedial care, is equal to or less than
17 100% of the federal poverty level.
18 (b) (Blank).
19 3. (Blank).
20 4. Persons not eligible under any of the preceding
21 paragraphs who fall sick, are injured, or die, not having
22 sufficient money, property or other resources to meet the
23 costs of necessary medical care or funeral and burial
24 expenses.
25 5.(a) Beginning January 1, 2020, individuals during
26 pregnancy and during the 12-month period beginning on the
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1 last day of the pregnancy, together with their infants,
2 whose income is at or below 200% of the federal poverty
3 level. Until September 30, 2019, or sooner if the
4 maintenance of effort requirements under the Patient
5 Protection and Affordable Care Act are eliminated or may
6 be waived before then, individuals during pregnancy and
7 during the 12-month period beginning on the last day of
8 the pregnancy, whose countable monthly income, after the
9 deduction of costs incurred for medical care and for other
10 types of remedial care as specified in administrative
11 rule, is equal to or less than the Medical Assistance-No
12 Grant(C) (MANG(C)) Income Standard in effect on April 1,
13 2013 as set forth in administrative rule.
14 (b) The plan for coverage shall provide ambulatory
15 prenatal care to pregnant individuals during a presumptive
16 eligibility period and establish an income eligibility
17 standard that is equal to 200% of the federal poverty
18 level, provided that costs incurred for medical care are
19 not taken into account in determining such income
20 eligibility.
21 (c) The Illinois Department may conduct a
22 demonstration in at least one county that will provide
23 medical assistance to pregnant individuals together with
24 their infants and children up to one year of age, where the
25 income eligibility standard is set up to 185% of the
26 nonfarm income official poverty line, as defined by the
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1 federal Office of Management and Budget. The Illinois
2 Department shall seek and obtain necessary authorization
3 provided under federal law to implement such a
4 demonstration. Such demonstration may establish resource
5 standards that are not more restrictive than those
6 established under Article IV of this Code.
7 6. (a) Subject to federal approval, children younger
8 than age 19 when countable income is at or below 313% of
9 the federal poverty level, as determined by the Department
10 and in accordance with all applicable federal
11 requirements. The Department is authorized to adopt
12 emergency rules to implement the changes made to this
13 paragraph by Public Act 102-43. Until September 30, 2019,
14 or sooner if the maintenance of effort requirements under
15 the Patient Protection and Affordable Care Act are
16 eliminated or may be waived before then, children younger
17 than age 19 whose countable monthly income, after the
18 deduction of costs incurred for medical care and for other
19 types of remedial care as specified in administrative
20 rule, is equal to or less than the Medical Assistance-No
21 Grant(C) (MANG(C)) Income Standard in effect on April 1,
22 2013 as set forth in administrative rule.
23 (b) Children and youth who are under temporary custody
24 or guardianship of the Department of Children and Family
25 Services or who receive financial assistance in support of
26 an adoption or guardianship placement from the Department
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1 of Children and Family Services.
2 7. (Blank).
3 8. As required under federal law, persons who are
4 eligible for Transitional Medical Assistance as a result
5 of an increase in earnings or child or spousal support
6 received. The plan for coverage for this class of persons
7 shall:
8 (a) extend the medical assistance coverage to the
9 extent required by federal law; and
10 (b) offer persons who have initially received 6
11 months of the coverage provided in paragraph (a)
12 above, the option of receiving an additional 6 months
13 of coverage, subject to the following:
14 (i) such coverage shall be pursuant to
15 provisions of the federal Social Security Act;
16 (ii) such coverage shall include all services
17 covered under Illinois' State Medicaid Plan;
18 (iii) no premium shall be charged for such
19 coverage; and
20 (iv) such coverage shall be suspended in the
21 event of a person's failure without good cause to
22 file in a timely fashion reports required for this
23 coverage under the Social Security Act and
24 coverage shall be reinstated upon the filing of
25 such reports if the person remains otherwise
26 eligible.
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1 9. Persons with acquired immunodeficiency syndrome
2 (AIDS) or with AIDS-related conditions with respect to
3 whom there has been a determination that but for home or
4 community-based services such individuals would require
5 the level of care provided in an inpatient hospital,
6 skilled nursing facility or intermediate care facility the
7 cost of which is reimbursed under this Article. Assistance
8 shall be provided to such persons to the maximum extent
9 permitted under Title XIX of the Federal Social Security
10 Act.
11 10. Participants in the long-term care insurance
12 partnership program established under the Illinois
13 Long-Term Care Partnership Program Act who meet the
14 qualifications for protection of resources described in
15 Section 15 of that Act.
16 11. Persons with disabilities who are employed and
17 eligible for Medicaid, pursuant to Section
18 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
19 subject to federal approval, persons with a medically
20 improved disability who are employed and eligible for
21 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
22 the Social Security Act, as provided by the Illinois
23 Department by rule. In establishing eligibility standards
24 under this paragraph 11, the Department shall, subject to
25 federal approval:
26 (a) set the income eligibility standard at not
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1 lower than 350% of the federal poverty level;
2 (b) exempt retirement accounts that the person
3 cannot access without penalty before the age of 59
4 1/2, and medical savings accounts established pursuant
5 to 26 U.S.C. 220;
6 (c) allow non-exempt assets up to $25,000 as to
7 those assets accumulated during periods of eligibility
8 under this paragraph 11; and
9 (d) continue to apply subparagraphs (b) and (c) in
10 determining the eligibility of the person under this
11 Article even if the person loses eligibility under
12 this paragraph 11.
13 12. Subject to federal approval, persons who are
14 eligible for medical assistance coverage under applicable
15 provisions of the federal Social Security Act and the
16 federal Breast and Cervical Cancer Prevention and
17 Treatment Act of 2000. Those eligible persons are defined
18 to include, but not be limited to, the following persons:
19 (1) persons who have been screened for breast or
20 cervical cancer under the U.S. Centers for Disease
21 Control and Prevention Breast and Cervical Cancer
22 Program established under Title XV of the federal
23 Public Health Service Act in accordance with the
24 requirements of Section 1504 of that Act as
25 administered by the Illinois Department of Public
26 Health; and
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1 (2) persons whose screenings under the above
2 program were funded in whole or in part by funds
3 appropriated to the Illinois Department of Public
4 Health for breast or cervical cancer screening.
5 "Medical assistance" under this paragraph 12 shall be
6 identical to the benefits provided under the State's
7 approved plan under Title XIX of the Social Security Act.
8 The Department must request federal approval of the
9 coverage under this paragraph 12 within 30 days after July
10 3, 2001 (the effective date of Public Act 92-47).
11 In addition to the persons who are eligible for
12 medical assistance pursuant to subparagraphs (1) and (2)
13 of this paragraph 12, and to be paid from funds
14 appropriated to the Department for its medical programs,
15 any uninsured person as defined by the Department in rules
16 residing in Illinois who is younger than 65 years of age,
17 who has been screened for breast and cervical cancer in
18 accordance with standards and procedures adopted by the
19 Department of Public Health for screening, and who is
20 referred to the Department by the Department of Public
21 Health as being in need of treatment for breast or
22 cervical cancer is eligible for medical assistance
23 benefits that are consistent with the benefits provided to
24 those persons described in subparagraphs (1) and (2).
25 Medical assistance coverage for the persons who are
26 eligible under the preceding sentence is not dependent on
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1 federal approval, but federal moneys may be used to pay
2 for services provided under that coverage upon federal
3 approval.
4 13. Subject to appropriation and to federal approval,
5 persons living with HIV/AIDS who are not otherwise
6 eligible under this Article and who qualify for services
7 covered under Section 5-5.04 as provided by the Illinois
8 Department by rule.
9 14. Subject to the availability of funds for this
10 purpose, the Department may provide coverage under this
11 Article to persons who reside in Illinois who are not
12 eligible under any of the preceding paragraphs and who
13 meet the income guidelines of paragraph 2(a) of this
14 Section and (i) have an application for asylum pending
15 before the federal Department of Homeland Security or on
16 appeal before a court of competent jurisdiction and are
17 represented either by counsel or by an advocate accredited
18 by the federal Department of Homeland Security and
19 employed by a not-for-profit organization in regard to
20 that application or appeal, or (ii) are receiving services
21 through a federally funded torture treatment center.
22 Medical coverage under this paragraph 14 may be provided
23 for up to 24 continuous months from the initial
24 eligibility date so long as an individual continues to
25 satisfy the criteria of this paragraph 14. If an
26 individual has an appeal pending regarding an application
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1 for asylum before the Department of Homeland Security,
2 eligibility under this paragraph 14 may be extended until
3 a final decision is rendered on the appeal. The Department
4 may adopt rules governing the implementation of this
5 paragraph 14.
6 15. Family Care Eligibility.
7 (a) On and after July 1, 2012, a parent or other
8 caretaker relative who is 19 years of age or older when
9 countable income is at or below 133% of the federal
10 poverty level. A person may not spend down to become
11 eligible under this paragraph 15.
12 (b) Eligibility shall be reviewed annually.
13 (c) (Blank).
14 (d) (Blank).
15 (e) (Blank).
16 (f) (Blank).
17 (g) (Blank).
18 (h) (Blank).
19 (i) Following termination of an individual's
20 coverage under this paragraph 15, the individual must
21 be determined eligible before the person can be
22 re-enrolled.
23 16. Subject to appropriation, uninsured persons who
24 are not otherwise eligible under this Section who have
25 been certified and referred by the Department of Public
26 Health as having been screened and found to need
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1 diagnostic evaluation or treatment, or both diagnostic
2 evaluation and treatment, for prostate or testicular
3 cancer. For the purposes of this paragraph 16, uninsured
4 persons are those who do not have creditable coverage, as
5 defined under the Health Insurance Portability and
6 Accountability Act, or have otherwise exhausted any
7 insurance benefits they may have had, for prostate or
8 testicular cancer diagnostic evaluation or treatment, or
9 both diagnostic evaluation and treatment. To be eligible,
10 a person must furnish a Social Security number. A person's
11 assets are exempt from consideration in determining
12 eligibility under this paragraph 16. Such persons shall be
13 eligible for medical assistance under this paragraph 16
14 for so long as they need treatment for the cancer. A person
15 shall be considered to need treatment if, in the opinion
16 of the person's treating physician, the person requires
17 therapy directed toward cure or palliation of prostate or
18 testicular cancer, including recurrent metastatic cancer
19 that is a known or presumed complication of prostate or
20 testicular cancer and complications resulting from the
21 treatment modalities themselves. Persons who require only
22 routine monitoring services are not considered to need
23 treatment. "Medical assistance" under this paragraph 16
24 shall be identical to the benefits provided under the
25 State's approved plan under Title XIX of the Social
26 Security Act. Notwithstanding any other provision of law,
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1 the Department (i) does not have a claim against the
2 estate of a deceased recipient of services under this
3 paragraph 16 and (ii) does not have a lien against any
4 homestead property or other legal or equitable real
5 property interest owned by a recipient of services under
6 this paragraph 16.
7 17. Persons who, pursuant to a waiver approved by the
8 Secretary of the U.S. Department of Health and Human
9 Services, are eligible for medical assistance under Title
10 XIX or XXI of the federal Social Security Act.
11 Notwithstanding any other provision of this Code and
12 consistent with the terms of the approved waiver, the
13 Illinois Department, may by rule:
14 (a) Limit the geographic areas in which the waiver
15 program operates.
16 (b) Determine the scope, quantity, duration, and
17 quality, and the rate and method of reimbursement, of
18 the medical services to be provided, which may differ
19 from those for other classes of persons eligible for
20 assistance under this Article.
21 (c) Restrict the persons' freedom in choice of
22 providers.
23 18. Beginning January 1, 2014, persons aged 19 or
24 older, but younger than 65, who are not otherwise eligible
25 for medical assistance under this Section 5-2, who qualify
26 for medical assistance pursuant to 42 U.S.C.
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1 1396a(a)(10)(A)(i)(VIII) and applicable federal
2 regulations, and who have income at or below 133% of the
3 federal poverty level plus 5% for the applicable family
4 size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
5 applicable federal regulations. Persons eligible for
6 medical assistance under this paragraph 18 shall receive
7 coverage for the Health Benefits Service Package as that
8 term is defined in subsection (m) of Section 5-1.1 of this
9 Code. If Illinois' federal medical assistance percentage
10 (FMAP) is reduced below 90% for persons eligible for
11 medical assistance under this paragraph 18, eligibility
12 under this paragraph 18 shall cease no later than the end
13 of the third month following the month in which the
14 reduction in FMAP takes effect.
15 19. Beginning January 1, 2014, as required under 42
16 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
17 and younger than age 26 who are not otherwise eligible for
18 medical assistance under paragraphs (1) through (17) of
19 this Section who (i) were in foster care under the
20 responsibility of the State on the date of attaining age
21 18 or on the date of attaining age 21 when a court has
22 continued wardship for good cause as provided in Section
23 2-31 of the Juvenile Court Act of 1987 and (ii) received
24 medical assistance under the Illinois Title XIX State Plan
25 or waiver of such plan while in foster care.
26 20. Beginning January 1, 2018, persons who are
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1 foreign-born victims of human trafficking, torture, or
2 other serious crimes as defined in Section 2-19 of this
3 Code and their derivative family members if such persons:
4 (i) reside in Illinois; (ii) are not eligible under any of
5 the preceding paragraphs; (iii) meet the income guidelines
6 of subparagraph (a) of paragraph 2; and (iv) meet the
7 nonfinancial eligibility requirements of Sections 16-2,
8 16-3, and 16-5 of this Code. The Department may extend
9 medical assistance for persons who are foreign-born
10 victims of human trafficking, torture, or other serious
11 crimes whose medical assistance would be terminated
12 pursuant to subsection (b) of Section 16-5 if the
13 Department determines that the person, during the year of
14 initial eligibility (1) experienced a health crisis, (2)
15 has been unable, after reasonable attempts, to obtain
16 necessary information from a third party, or (3) has other
17 extenuating circumstances that prevented the person from
18 completing his or her application for status. The
19 Department may adopt any rules necessary to implement the
20 provisions of this paragraph.
21 21. (Blank). Persons who are not otherwise eligible
22 for medical assistance under this Section who may qualify
23 for medical assistance pursuant to 42 U.S.C.
24 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
25 duration of any federal or State declared emergency due to
26 COVID-19. Medical assistance to persons eligible for
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1 medical assistance solely pursuant to this paragraph 21
2 shall be limited to any in vitro diagnostic product (and
3 the administration of such product) described in 42 U.S.C.
4 1396d(a)(3)(B) on or after March 18, 2020, any visit
5 described in 42 U.S.C. 1396o(a)(2)(G), or any other
6 medical assistance that may be federally authorized for
7 this class of persons. The Department may also cover
8 treatment of COVID-19 for this class of persons, or any
9 similar category of uninsured individuals, to the extent
10 authorized under a federally approved 1115 Waiver or other
11 federal authority. Notwithstanding the provisions of
12 Section 1-11 of this Code, due to the nature of the
13 COVID-19 public health emergency, the Department may cover
14 and provide the medical assistance described in this
15 paragraph 21 to noncitizens who would otherwise meet the
16 eligibility requirements for the class of persons
17 described in this paragraph 21 for the duration of the
18 State emergency period.
19 In implementing the provisions of Public Act 96-20, the
20 Department is authorized to adopt only those rules necessary,
21 including emergency rules. Nothing in Public Act 96-20 permits
22 the Department to adopt rules or issue a decision that expands
23 eligibility for the FamilyCare Program to a person whose
24 income exceeds 185% of the Federal Poverty Level as determined
25 from time to time by the U.S. Department of Health and Human
26 Services, unless the Department is provided with express
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1 statutory authority.
2 The eligibility of any such person for medical assistance
3 under this Article is not affected by the payment of any grant
4 under the Senior Citizens and Persons with Disabilities
5 Property Tax Relief Act or any distributions or items of
6 income described under subparagraph (X) of paragraph (2) of
7 subsection (a) of Section 203 of the Illinois Income Tax Act.
8 The Department shall by rule establish the amounts of
9 assets to be disregarded in determining eligibility for
10 medical assistance, which shall at a minimum equal the amounts
11 to be disregarded under the Federal Supplemental Security
12 Income Program. The amount of assets of a single person to be
13 disregarded shall not be less than $2,000, and the amount of
14 assets of a married couple to be disregarded shall not be less
15 than $3,000.
16 To the extent permitted under federal law, any person
17 found guilty of a second violation of Article VIIIA shall be
18 ineligible for medical assistance under this Article, as
19 provided in Section 8A-8.
20 The eligibility of any person for medical assistance under
21 this Article shall not be affected by the receipt by the person
22 of donations or benefits from fundraisers held for the person
23 in cases of serious illness, as long as neither the person nor
24 members of the person's family have actual control over the
25 donations or benefits or the disbursement of the donations or
26 benefits.
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1 Notwithstanding any other provision of this Code, if the
2 United States Supreme Court holds Title II, Subtitle A,
3 Section 2001(a) of Public Law 111-148 to be unconstitutional,
4 or if a holding of Public Law 111-148 makes Medicaid
5 eligibility allowed under Section 2001(a) inoperable, the
6 State or a unit of local government shall be prohibited from
7 enrolling individuals in the Medical Assistance Program as the
8 result of federal approval of a State Medicaid waiver on or
9 after June 14, 2012 (the effective date of Public Act 97-687),
10 and any individuals enrolled in the Medical Assistance Program
11 pursuant to eligibility permitted as a result of such a State
12 Medicaid waiver shall become immediately ineligible.
13 Notwithstanding any other provision of this Code, if an
14 Act of Congress that becomes a Public Law eliminates Section
15 2001(a) of Public Law 111-148, the State or a unit of local
16 government shall be prohibited from enrolling individuals in
17 the Medical Assistance Program as the result of federal
18 approval of a State Medicaid waiver on or after June 14, 2012
19 (the effective date of Public Act 97-687), and any individuals
20 enrolled in the Medical Assistance Program pursuant to
21 eligibility permitted as a result of such a State Medicaid
22 waiver shall become immediately ineligible.
23 Effective October 1, 2013, the determination of
24 eligibility of persons who qualify under paragraphs 5, 6, 8,
25 15, 17, and 18 of this Section shall comply with the
26 requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
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1 regulations.
2 The Department of Healthcare and Family Services, the
3 Department of Human Services, and the Illinois health
4 insurance marketplace shall work cooperatively to assist
5 persons who would otherwise lose health benefits as a result
6 of changes made under Public Act 98-104 to transition to other
7 health insurance coverage.
8 (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
9 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff.
10 10-8-21; 102-813, eff. 5-13-22.)
11 (305 ILCS 5/5-5)
12 (Text of Section before amendment by P.A. 103-808)
13 Sec. 5-5. Medical services. The Illinois Department, by
14 rule, shall determine the quantity and quality of and the rate
15 of reimbursement for the medical assistance for which payment
16 will be authorized, and the medical services to be provided,
17 which may include all or part of the following: (1) inpatient
18 hospital services; (2) outpatient hospital services; (3) other
19 laboratory and X-ray services; (4) skilled nursing home
20 services; (5) physicians' services whether furnished in the
21 office, the patient's home, a hospital, a skilled nursing
22 home, or elsewhere; (6) medical care, or any other type of
23 remedial care furnished by licensed practitioners; (7) home
24 health care services; (8) private duty nursing service; (9)
25 clinic services; (10) dental services, including prevention
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1 and treatment of periodontal disease and dental caries disease
2 for pregnant individuals, provided by an individual licensed
3 to practice dentistry or dental surgery; for purposes of this
4 item (10), "dental services" means diagnostic, preventive, or
5 corrective procedures provided by or under the supervision of
6 a dentist in the practice of his or her profession; (11)
7 physical therapy and related services; (12) prescribed drugs,
8 dentures, and prosthetic devices; and eyeglasses prescribed by
9 a physician skilled in the diseases of the eye, or by an
10 optometrist, whichever the person may select; (13) other
11 diagnostic, screening, preventive, and rehabilitative
12 services, including to ensure that the individual's need for
13 intervention or treatment of mental disorders or substance use
14 disorders or co-occurring mental health and substance use
15 disorders is determined using a uniform screening, assessment,
16 and evaluation process inclusive of criteria, for children and
17 adults; for purposes of this item (13), a uniform screening,
18 assessment, and evaluation process refers to a process that
19 includes an appropriate evaluation and, as warranted, a
20 referral; "uniform" does not mean the use of a singular
21 instrument, tool, or process that all must utilize; (14)
22 transportation and such other expenses as may be necessary;
23 (15) medical treatment of sexual assault survivors, as defined
24 in Section 1a of the Sexual Assault Survivors Emergency
25 Treatment Act, for injuries sustained as a result of the
26 sexual assault, including examinations and laboratory tests to
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1 discover evidence which may be used in criminal proceedings
2 arising from the sexual assault; (16) the diagnosis and
3 treatment of sickle cell anemia; (16.5) services performed by
4 a chiropractic physician licensed under the Medical Practice
5 Act of 1987 and acting within the scope of his or her license,
6 including, but not limited to, chiropractic manipulative
7 treatment; and (17) any other medical care, and any other type
8 of remedial care recognized under the laws of this State. The
9 term "any other type of remedial care" shall include nursing
10 care and nursing home service for persons who rely on
11 treatment by spiritual means alone through prayer for healing.
12 Notwithstanding any other provision of this Section, a
13 comprehensive tobacco use cessation program that includes
14 purchasing prescription drugs or prescription medical devices
15 approved by the Food and Drug Administration shall be covered
16 under the medical assistance program under this Article for
17 persons who are otherwise eligible for assistance under this
18 Article.
19 Notwithstanding any other provision of this Code,
20 reproductive health care that is otherwise legal in Illinois
21 shall be covered under the medical assistance program for
22 persons who are otherwise eligible for medical assistance
23 under this Article.
24 Notwithstanding any other provision of this Section, all
25 tobacco cessation medications approved by the United States
26 Food and Drug Administration and all individual and group
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1 tobacco cessation counseling services and telephone-based
2 counseling services and tobacco cessation medications provided
3 through the Illinois Tobacco Quitline shall be covered under
4 the medical assistance program for persons who are otherwise
5 eligible for assistance under this Article. The Department
6 shall comply with all federal requirements necessary to obtain
7 federal financial participation, as specified in 42 CFR
8 433.15(b)(7), for telephone-based counseling services provided
9 through the Illinois Tobacco Quitline, including, but not
10 limited to: (i) entering into a memorandum of understanding or
11 interagency agreement with the Department of Public Health, as
12 administrator of the Illinois Tobacco Quitline; and (ii)
13 developing a cost allocation plan for Medicaid-allowable
14 Illinois Tobacco Quitline services in accordance with 45 CFR
15 95.507. The Department shall submit the memorandum of
16 understanding or interagency agreement, the cost allocation
17 plan, and all other necessary documentation to the Centers for
18 Medicare and Medicaid Services for review and approval.
19 Coverage under this paragraph shall be contingent upon federal
20 approval.
21 Notwithstanding any other provision of this Code, the
22 Illinois Department may not require, as a condition of payment
23 for any laboratory test authorized under this Article, that a
24 physician's handwritten signature appear on the laboratory
25 test order form. The Illinois Department may, however, impose
26 other appropriate requirements regarding laboratory test order
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1 documentation.
2 Upon receipt of federal approval of an amendment to the
3 Illinois Title XIX State Plan for this purpose, the Department
4 shall authorize the Chicago Public Schools (CPS) to procure a
5 vendor or vendors to manufacture eyeglasses for individuals
6 enrolled in a school within the CPS system. CPS shall ensure
7 that its vendor or vendors are enrolled as providers in the
8 medical assistance program and in any capitated Medicaid
9 managed care entity (MCE) serving individuals enrolled in a
10 school within the CPS system. Under any contract procured
11 under this provision, the vendor or vendors must serve only
12 individuals enrolled in a school within the CPS system. Claims
13 for services provided by CPS's vendor or vendors to recipients
14 of benefits in the medical assistance program under this Code,
15 the Children's Health Insurance Program, or the Covering ALL
16 KIDS Health Insurance Program shall be submitted to the
17 Department or the MCE in which the individual is enrolled for
18 payment and shall be reimbursed at the Department's or the
19 MCE's established rates or rate methodologies for eyeglasses.
20 On and after July 1, 2012, the Department of Healthcare
21 and Family Services may provide the following services to
22 persons eligible for assistance under this Article who are
23 participating in education, training or employment programs
24 operated by the Department of Human Services as successor to
25 the Department of Public Aid:
26 (1) dental services provided by or under the
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1 supervision of a dentist; and
2 (2) eyeglasses prescribed by a physician skilled in
3 the diseases of the eye, or by an optometrist, whichever
4 the person may select.
5 On and after July 1, 2018, the Department of Healthcare
6 and Family Services shall provide dental services to any adult
7 who is otherwise eligible for assistance under the medical
8 assistance program. As used in this paragraph, "dental
9 services" means diagnostic, preventative, restorative, or
10 corrective procedures, including procedures and services for
11 the prevention and treatment of periodontal disease and dental
12 caries disease, provided by an individual who is licensed to
13 practice dentistry or dental surgery or who is under the
14 supervision of a dentist in the practice of his or her
15 profession.
16 On and after July 1, 2018, targeted dental services, as
17 set forth in Exhibit D of the Consent Decree entered by the
18 United States District Court for the Northern District of
19 Illinois, Eastern Division, in the matter of Memisovski v.
20 Maram, Case No. 92 C 1982, that are provided to adults under
21 the medical assistance program shall be established at no less
22 than the rates set forth in the "New Rate" column in Exhibit D
23 of the Consent Decree for targeted dental services that are
24 provided to persons under the age of 18 under the medical
25 assistance program.
26 Subject to federal approval, on and after January 1, 2025,
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1 the rates paid for sedation evaluation and the provision of
2 deep sedation and intravenous sedation for the purpose of
3 dental services shall be increased by 33% above the rates in
4 effect on December 31, 2024. The rates paid for nitrous oxide
5 sedation shall not be impacted by this paragraph and shall
6 remain the same as the rates in effect on December 31, 2024.
7 Notwithstanding any other provision of this Code and
8 subject to federal approval, the Department may adopt rules to
9 allow a dentist who is volunteering his or her service at no
10 cost to render dental services through an enrolled
11 not-for-profit health clinic without the dentist personally
12 enrolling as a participating provider in the medical
13 assistance program. A not-for-profit health clinic shall
14 include a public health clinic or Federally Qualified Health
15 Center or other enrolled provider, as determined by the
16 Department, through which dental services covered under this
17 Section are performed. The Department shall establish a
18 process for payment of claims for reimbursement for covered
19 dental services rendered under this provision.
20 Subject to appropriation and to federal approval, the
21 Department shall file administrative rules updating the
22 Handicapping Labio-Lingual Deviation orthodontic scoring tool
23 by January 1, 2025, or as soon as practicable.
24 On and after January 1, 2022, the Department of Healthcare
25 and Family Services shall administer and regulate a
26 school-based dental program that allows for the out-of-office
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1 delivery of preventative dental services in a school setting
2 to children under 19 years of age. The Department shall
3 establish, by rule, guidelines for participation by providers
4 and set requirements for follow-up referral care based on the
5 requirements established in the Dental Office Reference Manual
6 published by the Department that establishes the requirements
7 for dentists participating in the All Kids Dental School
8 Program. Every effort shall be made by the Department when
9 developing the program requirements to consider the different
10 geographic differences of both urban and rural areas of the
11 State for initial treatment and necessary follow-up care. No
12 provider shall be charged a fee by any unit of local government
13 to participate in the school-based dental program administered
14 by the Department. Nothing in this paragraph shall be
15 construed to limit or preempt a home rule unit's or school
16 district's authority to establish, change, or administer a
17 school-based dental program in addition to, or independent of,
18 the school-based dental program administered by the
19 Department.
20 The Illinois Department, by rule, may distinguish and
21 classify the medical services to be provided only in
22 accordance with the classes of persons designated in Section
23 5-2.
24 The Department of Healthcare and Family Services must
25 provide coverage and reimbursement for amino acid-based
26 elemental formulas, regardless of delivery method, for the
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1 diagnosis and treatment of (i) eosinophilic disorders and (ii)
2 short bowel syndrome when the prescribing physician has issued
3 a written order stating that the amino acid-based elemental
4 formula is medically necessary.
5 The Illinois Department shall authorize the provision of,
6 and shall authorize payment for, screening by low-dose
7 mammography for the presence of occult breast cancer for
8 individuals 35 years of age or older who are eligible for
9 medical assistance under this Article, as follows:
10 (A) A baseline mammogram for individuals 35 to 39
11 years of age.
12 (B) An annual mammogram for individuals 40 years of
13 age or older.
14 (C) A mammogram at the age and intervals considered
15 medically necessary by the individual's health care
16 provider for individuals under 40 years of age and having
17 a family history of breast cancer, prior personal history
18 of breast cancer, positive genetic testing, or other risk
19 factors.
20 (D) A comprehensive ultrasound screening and MRI of an
21 entire breast or breasts if a mammogram demonstrates
22 heterogeneous or dense breast tissue or when medically
23 necessary as determined by a physician licensed to
24 practice medicine in all of its branches.
25 (E) A screening MRI when medically necessary, as
26 determined by a physician licensed to practice medicine in
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1 all of its branches.
2 (F) A diagnostic mammogram when medically necessary,
3 as determined by a physician licensed to practice medicine
4 in all its branches, advanced practice registered nurse,
5 or physician assistant.
6 The Department shall not impose a deductible, coinsurance,
7 copayment, or any other cost-sharing requirement on the
8 coverage provided under this paragraph; except that this
9 sentence does not apply to coverage of diagnostic mammograms
10 to the extent such coverage would disqualify a high-deductible
11 health plan from eligibility for a health savings account
12 pursuant to Section 223 of the Internal Revenue Code (26
13 U.S.C. 223).
14 All screenings shall include a physical breast exam,
15 instruction on self-examination and information regarding the
16 frequency of self-examination and its value as a preventative
17 tool.
18 For purposes of this Section:
19 "Diagnostic mammogram" means a mammogram obtained using
20 diagnostic mammography.
21 "Diagnostic mammography" means a method of screening that
22 is designed to evaluate an abnormality in a breast, including
23 an abnormality seen or suspected on a screening mammogram or a
24 subjective or objective abnormality otherwise detected in the
25 breast.
26 "Low-dose mammography" means the x-ray examination of the
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1 breast using equipment dedicated specifically for mammography,
2 including the x-ray tube, filter, compression device, and
3 image receptor, with an average radiation exposure delivery of
4 less than one rad per breast for 2 views of an average size
5 breast. The term also includes digital mammography and
6 includes breast tomosynthesis.
7 "Breast tomosynthesis" means a radiologic procedure that
8 involves the acquisition of projection images over the
9 stationary breast to produce cross-sectional digital
10 three-dimensional images of the breast.
11 If, at any time, the Secretary of the United States
12 Department of Health and Human Services, or its successor
13 agency, promulgates rules or regulations to be published in
14 the Federal Register or publishes a comment in the Federal
15 Register or issues an opinion, guidance, or other action that
16 would require the State, pursuant to any provision of the
17 Patient Protection and Affordable Care Act (Public Law
18 111-148), including, but not limited to, 42 U.S.C.
19 18031(d)(3)(B) or any successor provision, to defray the cost
20 of any coverage for breast tomosynthesis outlined in this
21 paragraph, then the requirement that an insurer cover breast
22 tomosynthesis is inoperative other than any such coverage
23 authorized under Section 1902 of the Social Security Act, 42
24 U.S.C. 1396a, and the State shall not assume any obligation
25 for the cost of coverage for breast tomosynthesis set forth in
26 this paragraph.
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1 On and after January 1, 2016, the Department shall ensure
2 that all networks of care for adult clients of the Department
3 include access to at least one breast imaging Center of
4 Imaging Excellence as certified by the American College of
5 Radiology.
6 On and after January 1, 2012, providers participating in a
7 quality improvement program approved by the Department shall
8 be reimbursed for screening and diagnostic mammography at the
9 same rate as the Medicare program's rates, including the
10 increased reimbursement for digital mammography and, after
11 January 1, 2023 (the effective date of Public Act 102-1018),
12 breast tomosynthesis.
13 The Department shall convene an expert panel including
14 representatives of hospitals, free-standing mammography
15 facilities, and doctors, including radiologists, to establish
16 quality standards for mammography.
17 On and after January 1, 2017, providers participating in a
18 breast cancer treatment quality improvement program approved
19 by the Department shall be reimbursed for breast cancer
20 treatment at a rate that is no lower than 95% of the Medicare
21 program's rates for the data elements included in the breast
22 cancer treatment quality program.
23 The Department shall convene an expert panel, including
24 representatives of hospitals, free-standing breast cancer
25 treatment centers, breast cancer quality organizations, and
26 doctors, including breast surgeons, reconstructive breast
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1 surgeons, oncologists, and primary care providers to establish
2 quality standards for breast cancer treatment.
3 Subject to federal approval, the Department shall
4 establish a rate methodology for mammography at federally
5 qualified health centers and other encounter-rate clinics.
6 These clinics or centers may also collaborate with other
7 hospital-based mammography facilities. By January 1, 2016, the
8 Department shall report to the General Assembly on the status
9 of the provision set forth in this paragraph.
10 The Department shall establish a methodology to remind
11 individuals who are age-appropriate for screening mammography,
12 but who have not received a mammogram within the previous 18
13 months, of the importance and benefit of screening
14 mammography. The Department shall work with experts in breast
15 cancer outreach and patient navigation to optimize these
16 reminders and shall establish a methodology for evaluating
17 their effectiveness and modifying the methodology based on the
18 evaluation.
19 The Department shall establish a performance goal for
20 primary care providers with respect to their female patients
21 over age 40 receiving an annual mammogram. This performance
22 goal shall be used to provide additional reimbursement in the
23 form of a quality performance bonus to primary care providers
24 who meet that goal.
25 The Department shall devise a means of case-managing or
26 patient navigation for beneficiaries diagnosed with breast
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1 cancer. This program shall initially operate as a pilot
2 program in areas of the State with the highest incidence of
3 mortality related to breast cancer. At least one pilot program
4 site shall be in the metropolitan Chicago area and at least one
5 site shall be outside the metropolitan Chicago area. On or
6 after July 1, 2016, the pilot program shall be expanded to
7 include one site in western Illinois, one site in southern
8 Illinois, one site in central Illinois, and 4 sites within
9 metropolitan Chicago. An evaluation of the pilot program shall
10 be carried out measuring health outcomes and cost of care for
11 those served by the pilot program compared to similarly
12 situated patients who are not served by the pilot program.
13 The Department shall require all networks of care to
14 develop a means either internally or by contract with experts
15 in navigation and community outreach to navigate cancer
16 patients to comprehensive care in a timely fashion. The
17 Department shall require all networks of care to include
18 access for patients diagnosed with cancer to at least one
19 academic commission on cancer-accredited cancer program as an
20 in-network covered benefit.
21 The Department shall provide coverage and reimbursement
22 for a human papillomavirus (HPV) vaccine that is approved for
23 marketing by the federal Food and Drug Administration for all
24 persons between the ages of 9 and 45. Subject to federal
25 approval, the Department shall provide coverage and
26 reimbursement for a human papillomavirus (HPV) vaccine for
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1 persons of the age of 46 and above who have been diagnosed with
2 cervical dysplasia with a high risk of recurrence or
3 progression. The Department shall disallow any
4 preauthorization requirements for the administration of the
5 human papillomavirus (HPV) vaccine.
6 On or after July 1, 2022, individuals who are otherwise
7 eligible for medical assistance under this Article shall
8 receive coverage for perinatal depression screenings for the
9 12-month period beginning on the last day of their pregnancy.
10 Medical assistance coverage under this paragraph shall be
11 conditioned on the use of a screening instrument approved by
12 the Department.
13 Any medical or health care provider shall immediately
14 recommend, to any pregnant individual who is being provided
15 prenatal services and is suspected of having a substance use
16 disorder as defined in the Substance Use Disorder Act,
17 referral to a local substance use disorder treatment program
18 licensed by the Department of Human Services or to a licensed
19 hospital which provides substance abuse treatment services.
20 The Department of Healthcare and Family Services shall assure
21 coverage for the cost of treatment of the drug abuse or
22 addiction for pregnant recipients in accordance with the
23 Illinois Medicaid Program in conjunction with the Department
24 of Human Services.
25 All medical providers providing medical assistance to
26 pregnant individuals under this Code shall receive information
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1 from the Department on the availability of services under any
2 program providing case management services for addicted
3 individuals, including information on appropriate referrals
4 for other social services that may be needed by addicted
5 individuals in addition to treatment for addiction.
6 The Illinois Department, in cooperation with the
7 Departments of Human Services (as successor to the Department
8 of Alcoholism and Substance Abuse) and Public Health, through
9 a public awareness campaign, may provide information
10 concerning treatment for alcoholism and drug abuse and
11 addiction, prenatal health care, and other pertinent programs
12 directed at reducing the number of drug-affected infants born
13 to recipients of medical assistance.
14 Neither the Department of Healthcare and Family Services
15 nor the Department of Human Services shall sanction the
16 recipient solely on the basis of the recipient's substance
17 abuse.
18 The Illinois Department shall establish such regulations
19 governing the dispensing of health services under this Article
20 as it shall deem appropriate. The Department should seek the
21 advice of formal professional advisory committees appointed by
22 the Director of the Illinois Department for the purpose of
23 providing regular advice on policy and administrative matters,
24 information dissemination and educational activities for
25 medical and health care providers, and consistency in
26 procedures to the Illinois Department.
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1 The Illinois Department may develop and contract with
2 Partnerships of medical providers to arrange medical services
3 for persons eligible under Section 5-2 of this Code.
4 Implementation of this Section may be by demonstration
5 projects in certain geographic areas. The Partnership shall be
6 represented by a sponsor organization. The Department, by
7 rule, shall develop qualifications for sponsors of
8 Partnerships. Nothing in this Section shall be construed to
9 require that the sponsor organization be a medical
10 organization.
11 The sponsor must negotiate formal written contracts with
12 medical providers for physician services, inpatient and
13 outpatient hospital care, home health services, treatment for
14 alcoholism and substance abuse, and other services determined
15 necessary by the Illinois Department by rule for delivery by
16 Partnerships. Physician services must include prenatal and
17 obstetrical care. The Illinois Department shall reimburse
18 medical services delivered by Partnership providers to clients
19 in target areas according to provisions of this Article and
20 the Illinois Health Finance Reform Act, except that:
21 (1) Physicians participating in a Partnership and
22 providing certain services, which shall be determined by
23 the Illinois Department, to persons in areas covered by
24 the Partnership may receive an additional surcharge for
25 such services.
26 (2) The Department may elect to consider and negotiate
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1 financial incentives to encourage the development of
2 Partnerships and the efficient delivery of medical care.
3 (3) Persons receiving medical services through
4 Partnerships may receive medical and case management
5 services above the level usually offered through the
6 medical assistance program.
7 Medical providers shall be required to meet certain
8 qualifications to participate in Partnerships to ensure the
9 delivery of high quality medical services. These
10 qualifications shall be determined by rule of the Illinois
11 Department and may be higher than qualifications for
12 participation in the medical assistance program. Partnership
13 sponsors may prescribe reasonable additional qualifications
14 for participation by medical providers, only with the prior
15 written approval of the Illinois Department.
16 Nothing in this Section shall limit the free choice of
17 practitioners, hospitals, and other providers of medical
18 services by clients. In order to ensure patient freedom of
19 choice, the Illinois Department shall immediately promulgate
20 all rules and take all other necessary actions so that
21 provided services may be accessed from therapeutically
22 certified optometrists to the full extent of the Illinois
23 Optometric Practice Act of 1987 without discriminating between
24 service providers.
25 The Department shall apply for a waiver from the United
26 States Health Care Financing Administration to allow for the
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1 implementation of Partnerships under this Section.
2 The Illinois Department shall require health care
3 providers to maintain records that document the medical care
4 and services provided to recipients of Medical Assistance
5 under this Article. Such records must be retained for a period
6 of not less than 6 years from the date of service or as
7 provided by applicable State law, whichever period is longer,
8 except that if an audit is initiated within the required
9 retention period then the records must be retained until the
10 audit is completed and every exception is resolved. The
11 Illinois Department shall require health care providers to
12 make available, when authorized by the patient, in writing,
13 the medical records in a timely fashion to other health care
14 providers who are treating or serving persons eligible for
15 Medical Assistance under this Article. All dispensers of
16 medical services shall be required to maintain and retain
17 business and professional records sufficient to fully and
18 accurately document the nature, scope, details and receipt of
19 the health care provided to persons eligible for medical
20 assistance under this Code, in accordance with regulations
21 promulgated by the Illinois Department. The rules and
22 regulations shall require that proof of the receipt of
23 prescription drugs, dentures, prosthetic devices and
24 eyeglasses by eligible persons under this Section accompany
25 each claim for reimbursement submitted by the dispenser of
26 such medical services. No such claims for reimbursement shall
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1 be approved for payment by the Illinois Department without
2 such proof of receipt, unless the Illinois Department shall
3 have put into effect and shall be operating a system of
4 post-payment audit and review which shall, on a sampling
5 basis, be deemed adequate by the Illinois Department to assure
6 that such drugs, dentures, prosthetic devices and eyeglasses
7 for which payment is being made are actually being received by
8 eligible recipients. Within 90 days after September 16, 1984
9 (the effective date of Public Act 83-1439), the Illinois
10 Department shall establish a current list of acquisition costs
11 for all prosthetic devices and any other items recognized as
12 medical equipment and supplies reimbursable under this Article
13 and shall update such list on a quarterly basis, except that
14 the acquisition costs of all prescription drugs shall be
15 updated no less frequently than every 30 days as required by
16 Section 5-5.12.
17 Notwithstanding any other law to the contrary, the
18 Illinois Department shall, within 365 days after July 22, 2013
19 (the effective date of Public Act 98-104), establish
20 procedures to permit skilled care facilities licensed under
21 the Nursing Home Care Act to submit monthly billing claims for
22 reimbursement purposes. Following development of these
23 procedures, the Department shall, by July 1, 2016, test the
24 viability of the new system and implement any necessary
25 operational or structural changes to its information
26 technology platforms in order to allow for the direct
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1 acceptance and payment of nursing home claims.
2 Notwithstanding any other law to the contrary, the
3 Illinois Department shall, within 365 days after August 15,
4 2014 (the effective date of Public Act 98-963), establish
5 procedures to permit ID/DD facilities licensed under the ID/DD
6 Community Care Act and MC/DD facilities licensed under the
7 MC/DD Act to submit monthly billing claims for reimbursement
8 purposes. Following development of these procedures, the
9 Department shall have an additional 365 days to test the
10 viability of the new system and to ensure that any necessary
11 operational or structural changes to its information
12 technology platforms are implemented.
13 The Illinois Department shall require all dispensers of
14 medical services, other than an individual practitioner or
15 group of practitioners, desiring to participate in the Medical
16 Assistance program established under this Article to disclose
17 all financial, beneficial, ownership, equity, surety or other
18 interests in any and all firms, corporations, partnerships,
19 associations, business enterprises, joint ventures, agencies,
20 institutions or other legal entities providing any form of
21 health care services in this State under this Article.
22 The Illinois Department may require that all dispensers of
23 medical services desiring to participate in the medical
24 assistance program established under this Article disclose,
25 under such terms and conditions as the Illinois Department may
26 by rule establish, all inquiries from clients and attorneys
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1 regarding medical bills paid by the Illinois Department, which
2 inquiries could indicate potential existence of claims or
3 liens for the Illinois Department.
4 Enrollment of a vendor shall be subject to a provisional
5 period and shall be conditional for one year. During the
6 period of conditional enrollment, the Department may terminate
7 the vendor's eligibility to participate in, or may disenroll
8 the vendor from, the medical assistance program without cause.
9 Unless otherwise specified, such termination of eligibility or
10 disenrollment is not subject to the Department's hearing
11 process. However, a disenrolled vendor may reapply without
12 penalty.
13 The Department has the discretion to limit the conditional
14 enrollment period for vendors based upon the category of risk
15 of the vendor.
16 Prior to enrollment and during the conditional enrollment
17 period in the medical assistance program, all vendors shall be
18 subject to enhanced oversight, screening, and review based on
19 the risk of fraud, waste, and abuse that is posed by the
20 category of risk of the vendor. The Illinois Department shall
21 establish the procedures for oversight, screening, and review,
22 which may include, but need not be limited to: criminal and
23 financial background checks; fingerprinting; license,
24 certification, and authorization verifications; unscheduled or
25 unannounced site visits; database checks; prepayment audit
26 reviews; audits; payment caps; payment suspensions; and other
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1 screening as required by federal or State law.
2 The Department shall define or specify the following: (i)
3 by provider notice, the "category of risk of the vendor" for
4 each type of vendor, which shall take into account the level of
5 screening applicable to a particular category of vendor under
6 federal law and regulations; (ii) by rule or provider notice,
7 the maximum length of the conditional enrollment period for
8 each category of risk of the vendor; and (iii) by rule, the
9 hearing rights, if any, afforded to a vendor in each category
10 of risk of the vendor that is terminated or disenrolled during
11 the conditional enrollment period.
12 To be eligible for payment consideration, a vendor's
13 payment claim or bill, either as an initial claim or as a
14 resubmitted claim following prior rejection, must be received
15 by the Illinois Department, or its fiscal intermediary, no
16 later than 180 days after the latest date on the claim on which
17 medical goods or services were provided, with the following
18 exceptions:
19 (1) In the case of a provider whose enrollment is in
20 process by the Illinois Department, the 180-day period
21 shall not begin until the date on the written notice from
22 the Illinois Department that the provider enrollment is
23 complete.
24 (2) In the case of errors attributable to the Illinois
25 Department or any of its claims processing intermediaries
26 which result in an inability to receive, process, or
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1 adjudicate a claim, the 180-day period shall not begin
2 until the provider has been notified of the error.
3 (3) In the case of a provider for whom the Illinois
4 Department initiates the monthly billing process.
5 (4) In the case of a provider operated by a unit of
6 local government with a population exceeding 3,000,000
7 when local government funds finance federal participation
8 for claims payments.
9 For claims for services rendered during a period for which
10 a recipient received retroactive eligibility, claims must be
11 filed within 180 days after the Department determines the
12 applicant is eligible. For claims for which the Illinois
13 Department is not the primary payer, claims must be submitted
14 to the Illinois Department within 180 days after the final
15 adjudication by the primary payer.
16 In the case of long term care facilities, within 120
17 calendar days of receipt by the facility of required
18 prescreening information, new admissions with associated
19 admission documents shall be submitted through the Medical
20 Electronic Data Interchange (MEDI) or the Recipient
21 Eligibility Verification (REV) System or shall be submitted
22 directly to the Department of Human Services using required
23 admission forms. Effective September 1, 2014, admission
24 documents, including all prescreening information, must be
25 submitted through MEDI or REV. Confirmation numbers assigned
26 to an accepted transaction shall be retained by a facility to
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1 verify timely submittal. Once an admission transaction has
2 been completed, all resubmitted claims following prior
3 rejection are subject to receipt no later than 180 days after
4 the admission transaction has been completed.
5 Claims that are not submitted and received in compliance
6 with the foregoing requirements shall not be eligible for
7 payment under the medical assistance program, and the State
8 shall have no liability for payment of those claims.
9 To the extent consistent with applicable information and
10 privacy, security, and disclosure laws, State and federal
11 agencies and departments shall provide the Illinois Department
12 access to confidential and other information and data
13 necessary to perform eligibility and payment verifications and
14 other Illinois Department functions. This includes, but is not
15 limited to: information pertaining to licensure;
16 certification; earnings; immigration status; citizenship; wage
17 reporting; unearned and earned income; pension income;
18 employment; supplemental security income; social security
19 numbers; National Provider Identifier (NPI) numbers; the
20 National Practitioner Data Bank (NPDB); program and agency
21 exclusions; taxpayer identification numbers; tax delinquency;
22 corporate information; and death records.
23 The Illinois Department shall enter into agreements with
24 State agencies and departments, and is authorized to enter
25 into agreements with federal agencies and departments, under
26 which such agencies and departments shall share data necessary
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1 for medical assistance program integrity functions and
2 oversight. The Illinois Department shall develop, in
3 cooperation with other State departments and agencies, and in
4 compliance with applicable federal laws and regulations,
5 appropriate and effective methods to share such data. At a
6 minimum, and to the extent necessary to provide data sharing,
7 the Illinois Department shall enter into agreements with State
8 agencies and departments, and is authorized to enter into
9 agreements with federal agencies and departments, including,
10 but not limited to: the Secretary of State; the Department of
11 Revenue; the Department of Public Health; the Department of
12 Human Services; and the Department of Financial and
13 Professional Regulation.
14 Beginning in fiscal year 2013, the Illinois Department
15 shall set forth a request for information to identify the
16 benefits of a pre-payment, post-adjudication, and post-edit
17 claims system with the goals of streamlining claims processing
18 and provider reimbursement, reducing the number of pending or
19 rejected claims, and helping to ensure a more transparent
20 adjudication process through the utilization of: (i) provider
21 data verification and provider screening technology; and (ii)
22 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
23 post-adjudicated predictive modeling with an integrated case
24 management system with link analysis. Such a request for
25 information shall not be considered as a request for proposal
26 or as an obligation on the part of the Illinois Department to
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1 take any action or acquire any products or services.
2 The Illinois Department shall establish policies,
3 procedures, standards and criteria by rule for the
4 acquisition, repair and replacement of orthotic and prosthetic
5 devices and durable medical equipment. Such rules shall
6 provide, but not be limited to, the following services: (1)
7 immediate repair or replacement of such devices by recipients;
8 and (2) rental, lease, purchase or lease-purchase of durable
9 medical equipment in a cost-effective manner, taking into
10 consideration the recipient's medical prognosis, the extent of
11 the recipient's needs, and the requirements and costs for
12 maintaining such equipment. Subject to prior approval, such
13 rules shall enable a recipient to temporarily acquire and use
14 alternative or substitute devices or equipment pending repairs
15 or replacements of any device or equipment previously
16 authorized for such recipient by the Department.
17 Notwithstanding any provision of Section 5-5f to the contrary,
18 the Department may, by rule, exempt certain replacement
19 wheelchair parts from prior approval and, for wheelchairs,
20 wheelchair parts, wheelchair accessories, and related seating
21 and positioning items, determine the wholesale price by
22 methods other than actual acquisition costs.
23 The Department shall require, by rule, all providers of
24 durable medical equipment to be accredited by an accreditation
25 organization approved by the federal Centers for Medicare and
26 Medicaid Services and recognized by the Department in order to
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1 bill the Department for providing durable medical equipment to
2 recipients. No later than 15 months after the effective date
3 of the rule adopted pursuant to this paragraph, all providers
4 must meet the accreditation requirement.
5 In order to promote environmental responsibility, meet the
6 needs of recipients and enrollees, and achieve significant
7 cost savings, the Department, or a managed care organization
8 under contract with the Department, may provide recipients or
9 managed care enrollees who have a prescription or Certificate
10 of Medical Necessity access to refurbished durable medical
11 equipment under this Section (excluding prosthetic and
12 orthotic devices as defined in the Orthotics, Prosthetics, and
13 Pedorthics Practice Act and complex rehabilitation technology
14 products and associated services) through the State's
15 assistive technology program's reutilization program, using
16 staff with the Assistive Technology Professional (ATP)
17 Certification if the refurbished durable medical equipment:
18 (i) is available; (ii) is less expensive, including shipping
19 costs, than new durable medical equipment of the same type;
20 (iii) is able to withstand at least 3 years of use; (iv) is
21 cleaned, disinfected, sterilized, and safe in accordance with
22 federal Food and Drug Administration regulations and guidance
23 governing the reprocessing of medical devices in health care
24 settings; and (v) equally meets the needs of the recipient or
25 enrollee. The reutilization program shall confirm that the
26 recipient or enrollee is not already in receipt of the same or
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1 similar equipment from another service provider, and that the
2 refurbished durable medical equipment equally meets the needs
3 of the recipient or enrollee. Nothing in this paragraph shall
4 be construed to limit recipient or enrollee choice to obtain
5 new durable medical equipment or place any additional prior
6 authorization conditions on enrollees of managed care
7 organizations.
8 The Department shall execute, relative to the nursing home
9 prescreening project, written inter-agency agreements with the
10 Department of Human Services and the Department on Aging, to
11 effect the following: (i) intake procedures and common
12 eligibility criteria for those persons who are receiving
13 non-institutional services; and (ii) the establishment and
14 development of non-institutional services in areas of the
15 State where they are not currently available or are
16 undeveloped; and (iii) notwithstanding any other provision of
17 law, subject to federal approval, on and after July 1, 2012, an
18 increase in the determination of need (DON) scores from 29 to
19 37 for applicants for institutional and home and
20 community-based long term care; if and only if federal
21 approval is not granted, the Department may, in conjunction
22 with other affected agencies, implement utilization controls
23 or changes in benefit packages to effectuate a similar savings
24 amount for this population; and (iv) no later than July 1,
25 2013, minimum level of care eligibility criteria for
26 institutional and home and community-based long term care; and
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1 (v) no later than October 1, 2013, establish procedures to
2 permit long term care providers access to eligibility scores
3 for individuals with an admission date who are seeking or
4 receiving services from the long term care provider. In order
5 to select the minimum level of care eligibility criteria, the
6 Governor shall establish a workgroup that includes affected
7 agency representatives and stakeholders representing the
8 institutional and home and community-based long term care
9 interests. This Section shall not restrict the Department from
10 implementing lower level of care eligibility criteria for
11 community-based services in circumstances where federal
12 approval has been granted.
13 The Illinois Department shall develop and operate, in
14 cooperation with other State Departments and agencies and in
15 compliance with applicable federal laws and regulations,
16 appropriate and effective systems of health care evaluation
17 and programs for monitoring of utilization of health care
18 services and facilities, as it affects persons eligible for
19 medical assistance under this Code.
20 The Illinois Department shall report annually to the
21 General Assembly, no later than the second Friday in April of
22 1979 and each year thereafter, in regard to:
23 (a) actual statistics and trends in utilization of
24 medical services by public aid recipients;
25 (b) actual statistics and trends in the provision of
26 the various medical services by medical vendors;
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1 (c) current rate structures and proposed changes in
2 those rate structures for the various medical vendors; and
3 (d) efforts at utilization review and control by the
4 Illinois Department.
5 The period covered by each report shall be the 3 years
6 ending on the June 30 prior to the report. The report shall
7 include suggested legislation for consideration by the General
8 Assembly. The requirement for reporting to the General
9 Assembly shall be satisfied by filing copies of the report as
10 required by Section 3.1 of the General Assembly Organization
11 Act, and filing such additional copies with the State
12 Government Report Distribution Center for the General Assembly
13 as is required under paragraph (t) of Section 7 of the State
14 Library Act.
15 Rulemaking authority to implement Public Act 95-1045, if
16 any, is conditioned on the rules being adopted in accordance
17 with all provisions of the Illinois Administrative Procedure
18 Act and all rules and procedures of the Joint Committee on
19 Administrative Rules; any purported rule not so adopted, for
20 whatever reason, is unauthorized.
21 On and after July 1, 2012, the Department shall reduce any
22 rate of reimbursement for services or other payments or alter
23 any methodologies authorized by this Code to reduce any rate
24 of reimbursement for services or other payments in accordance
25 with Section 5-5e.
26 Because kidney transplantation can be an appropriate,
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1 cost-effective alternative to renal dialysis when medically
2 necessary and notwithstanding the provisions of Section 1-11
3 of this Code, beginning October 1, 2014, the Department shall
4 cover kidney transplantation for noncitizens with end-stage
5 renal disease who are not eligible for comprehensive medical
6 benefits, who meet the residency requirements of Section 5-3
7 of this Code, and who would otherwise meet the financial
8 requirements of the appropriate class of eligible persons
9 under Section 5-2 of this Code. To qualify for coverage of
10 kidney transplantation, such person must be receiving
11 emergency renal dialysis services covered by the Department.
12 Providers under this Section shall be prior approved and
13 certified by the Department to perform kidney transplantation
14 and the services under this Section shall be limited to
15 services associated with kidney transplantation.
16 Notwithstanding any other provision of this Code to the
17 contrary, on or after July 1, 2015, all FDA-approved FDA
18 approved forms of medication assisted treatment prescribed for
19 the treatment of alcohol dependence or treatment of opioid
20 dependence shall be covered under both fee-for-service and
21 managed care medical assistance programs for persons who are
22 otherwise eligible for medical assistance under this Article
23 and shall not be subject to any (1) utilization control, other
24 than those established under the American Society of Addiction
25 Medicine patient placement criteria, (2) prior authorization
26 mandate, (3) lifetime restriction limit mandate, or (4)
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1 limitations on dosage.
2 On or after July 1, 2015, opioid antagonists prescribed
3 for the treatment of an opioid overdose, including the
4 medication product, administration devices, and any pharmacy
5 fees or hospital fees related to the dispensing, distribution,
6 and administration of the opioid antagonist, shall be covered
7 under the medical assistance program for persons who are
8 otherwise eligible for medical assistance under this Article.
9 As used in this Section, "opioid antagonist" means a drug that
10 binds to opioid receptors and blocks or inhibits the effect of
11 opioids acting on those receptors, including, but not limited
12 to, naloxone hydrochloride or any other similarly acting drug
13 approved by the U.S. Food and Drug Administration. The
14 Department shall not impose a copayment on the coverage
15 provided for naloxone hydrochloride under the medical
16 assistance program.
17 Upon federal approval, the Department shall provide
18 coverage and reimbursement for all drugs that are approved for
19 marketing by the federal Food and Drug Administration and that
20 are recommended by the federal Public Health Service or the
21 United States Centers for Disease Control and Prevention for
22 pre-exposure prophylaxis and related pre-exposure prophylaxis
23 services, including, but not limited to, HIV and sexually
24 transmitted infection screening, treatment for sexually
25 transmitted infections, medical monitoring, assorted labs, and
26 counseling to reduce the likelihood of HIV infection among
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1 individuals who are not infected with HIV but who are at high
2 risk of HIV infection.
3 A federally qualified health center, as defined in Section
4 1905(l)(2)(B) of the federal Social Security Act, shall be
5 reimbursed by the Department in accordance with the federally
6 qualified health center's encounter rate for services provided
7 to medical assistance recipients that are performed by a
8 dental hygienist, as defined under the Illinois Dental
9 Practice Act, working under the general supervision of a
10 dentist and employed by a federally qualified health center.
11 Within 90 days after October 8, 2021 (the effective date
12 of Public Act 102-665), the Department shall seek federal
13 approval of a State Plan amendment to expand coverage for
14 family planning services that includes presumptive eligibility
15 to individuals whose income is at or below 208% of the federal
16 poverty level. Coverage under this Section shall be effective
17 beginning no later than December 1, 2022.
18 Subject to approval by the federal Centers for Medicare
19 and Medicaid Services of a Title XIX State Plan amendment
20 electing the Program of All-Inclusive Care for the Elderly
21 (PACE) as a State Medicaid option, as provided for by Subtitle
22 I (commencing with Section 4801) of Title IV of the Balanced
23 Budget Act of 1997 (Public Law 105-33) and Part 460
24 (commencing with Section 460.2) of Subchapter E of Title 42 of
25 the Code of Federal Regulations, PACE program services shall
26 become a covered benefit of the medical assistance program,
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1 subject to criteria established in accordance with all
2 applicable laws.
3 Notwithstanding any other provision of this Code,
4 community-based pediatric palliative care from a trained
5 interdisciplinary team shall be covered under the medical
6 assistance program as provided in Section 15 of the Pediatric
7 Palliative Care Act.
8 Notwithstanding any other provision of this Code, within
9 12 months after June 2, 2022 (the effective date of Public Act
10 102-1037) and subject to federal approval, acupuncture
11 services performed by an acupuncturist licensed under the
12 Acupuncture Practice Act who is acting within the scope of his
13 or her license shall be covered under the medical assistance
14 program. The Department shall apply for any federal waiver or
15 State Plan amendment, if required, to implement this
16 paragraph. The Department may adopt any rules, including
17 standards and criteria, necessary to implement this paragraph.
18 Notwithstanding any other provision of this Code, the
19 medical assistance program shall, subject to federal approval,
20 reimburse hospitals for costs associated with a newborn
21 screening test for the presence of metachromatic
22 leukodystrophy, as required under the Newborn Metabolic
23 Screening Act, at a rate not less than the fee charged by the
24 Department of Public Health. Notwithstanding any other
25 provision of this Code, the medical assistance program shall,
26 subject to appropriation and federal approval, also reimburse
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1 hospitals for costs associated with all newborn screening
2 tests added on and after August 9, 2024 (the effective date of
3 Public Act 103-909) this amendatory Act of the 103rd General
4 Assembly to the Newborn Metabolic Screening Act and required
5 to be performed under that Act at a rate not less than the fee
6 charged by the Department of Public Health. The Department
7 shall seek federal approval before the implementation of the
8 newborn screening test fees by the Department of Public
9 Health.
10 Notwithstanding any other provision of this Code,
11 beginning on January 1, 2024, subject to federal approval,
12 cognitive assessment and care planning services provided to a
13 person who experiences signs or symptoms of cognitive
14 impairment, as defined by the Diagnostic and Statistical
15 Manual of Mental Disorders, Fifth Edition, shall be covered
16 under the medical assistance program for persons who are
17 otherwise eligible for medical assistance under this Article.
18 Notwithstanding any other provision of this Code,
19 medically necessary reconstructive services that are intended
20 to restore physical appearance shall be covered under the
21 medical assistance program for persons who are otherwise
22 eligible for medical assistance under this Article. As used in
23 this paragraph, "reconstructive services" means treatments
24 performed on structures of the body damaged by trauma to
25 restore physical appearance.
26 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
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1 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
3 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
4 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
6 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
7 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
8 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
9 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
10 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
11 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
12 10-10-24.)
13 (Text of Section after amendment by P.A. 103-808)
14 Sec. 5-5. Medical services. The Illinois Department, by
15 rule, shall determine the quantity and quality of and the rate
16 of reimbursement for the medical assistance for which payment
17 will be authorized, and the medical services to be provided,
18 which may include all or part of the following: (1) inpatient
19 hospital services; (2) outpatient hospital services; (3) other
20 laboratory and X-ray services; (4) skilled nursing home
21 services; (5) physicians' services whether furnished in the
22 office, the patient's home, a hospital, a skilled nursing
23 home, or elsewhere; (6) medical care, or any other type of
24 remedial care furnished by licensed practitioners; (7) home
25 health care services; (8) private duty nursing service; (9)
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1 clinic services; (10) dental services, including prevention
2 and treatment of periodontal disease and dental caries disease
3 for pregnant individuals, provided by an individual licensed
4 to practice dentistry or dental surgery; for purposes of this
5 item (10), "dental services" means diagnostic, preventive, or
6 corrective procedures provided by or under the supervision of
7 a dentist in the practice of his or her profession; (11)
8 physical therapy and related services; (12) prescribed drugs,
9 dentures, and prosthetic devices; and eyeglasses prescribed by
10 a physician skilled in the diseases of the eye, or by an
11 optometrist, whichever the person may select; (13) other
12 diagnostic, screening, preventive, and rehabilitative
13 services, including to ensure that the individual's need for
14 intervention or treatment of mental disorders or substance use
15 disorders or co-occurring mental health and substance use
16 disorders is determined using a uniform screening, assessment,
17 and evaluation process inclusive of criteria, for children and
18 adults; for purposes of this item (13), a uniform screening,
19 assessment, and evaluation process refers to a process that
20 includes an appropriate evaluation and, as warranted, a
21 referral; "uniform" does not mean the use of a singular
22 instrument, tool, or process that all must utilize; (14)
23 transportation and such other expenses as may be necessary;
24 (15) medical treatment of sexual assault survivors, as defined
25 in Section 1a of the Sexual Assault Survivors Emergency
26 Treatment Act, for injuries sustained as a result of the
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1 sexual assault, including examinations and laboratory tests to
2 discover evidence which may be used in criminal proceedings
3 arising from the sexual assault; (16) the diagnosis and
4 treatment of sickle cell anemia; (16.5) services performed by
5 a chiropractic physician licensed under the Medical Practice
6 Act of 1987 and acting within the scope of his or her license,
7 including, but not limited to, chiropractic manipulative
8 treatment; and (17) any other medical care, and any other type
9 of remedial care recognized under the laws of this State. The
10 term "any other type of remedial care" shall include nursing
11 care and nursing home service for persons who rely on
12 treatment by spiritual means alone through prayer for healing.
13 Notwithstanding any other provision of this Section, a
14 comprehensive tobacco use cessation program that includes
15 purchasing prescription drugs or prescription medical devices
16 approved by the Food and Drug Administration shall be covered
17 under the medical assistance program under this Article for
18 persons who are otherwise eligible for assistance under this
19 Article.
20 Notwithstanding any other provision of this Code,
21 reproductive health care that is otherwise legal in Illinois
22 shall be covered under the medical assistance program for
23 persons who are otherwise eligible for medical assistance
24 under this Article.
25 Notwithstanding any other provision of this Section, all
26 tobacco cessation medications approved by the United States
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1 Food and Drug Administration and all individual and group
2 tobacco cessation counseling services and telephone-based
3 counseling services and tobacco cessation medications provided
4 through the Illinois Tobacco Quitline shall be covered under
5 the medical assistance program for persons who are otherwise
6 eligible for assistance under this Article. The Department
7 shall comply with all federal requirements necessary to obtain
8 federal financial participation, as specified in 42 CFR
9 433.15(b)(7), for telephone-based counseling services provided
10 through the Illinois Tobacco Quitline, including, but not
11 limited to: (i) entering into a memorandum of understanding or
12 interagency agreement with the Department of Public Health, as
13 administrator of the Illinois Tobacco Quitline; and (ii)
14 developing a cost allocation plan for Medicaid-allowable
15 Illinois Tobacco Quitline services in accordance with 45 CFR
16 95.507. The Department shall submit the memorandum of
17 understanding or interagency agreement, the cost allocation
18 plan, and all other necessary documentation to the Centers for
19 Medicare and Medicaid Services for review and approval.
20 Coverage under this paragraph shall be contingent upon federal
21 approval.
22 Notwithstanding any other provision of this Code, the
23 Illinois Department may not require, as a condition of payment
24 for any laboratory test authorized under this Article, that a
25 physician's handwritten signature appear on the laboratory
26 test order form. The Illinois Department may, however, impose
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1 other appropriate requirements regarding laboratory test order
2 documentation.
3 Upon receipt of federal approval of an amendment to the
4 Illinois Title XIX State Plan for this purpose, the Department
5 shall authorize the Chicago Public Schools (CPS) to procure a
6 vendor or vendors to manufacture eyeglasses for individuals
7 enrolled in a school within the CPS system. CPS shall ensure
8 that its vendor or vendors are enrolled as providers in the
9 medical assistance program and in any capitated Medicaid
10 managed care entity (MCE) serving individuals enrolled in a
11 school within the CPS system. Under any contract procured
12 under this provision, the vendor or vendors must serve only
13 individuals enrolled in a school within the CPS system. Claims
14 for services provided by CPS's vendor or vendors to recipients
15 of benefits in the medical assistance program under this Code,
16 the Children's Health Insurance Program, or the Covering ALL
17 KIDS Health Insurance Program shall be submitted to the
18 Department or the MCE in which the individual is enrolled for
19 payment and shall be reimbursed at the Department's or the
20 MCE's established rates or rate methodologies for eyeglasses.
21 On and after July 1, 2012, the Department of Healthcare
22 and Family Services may provide the following services to
23 persons eligible for assistance under this Article who are
24 participating in education, training or employment programs
25 operated by the Department of Human Services as successor to
26 the Department of Public Aid:
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1 (1) dental services provided by or under the
2 supervision of a dentist; and
3 (2) eyeglasses prescribed by a physician skilled in
4 the diseases of the eye, or by an optometrist, whichever
5 the person may select.
6 On and after July 1, 2018, the Department of Healthcare
7 and Family Services shall provide dental services to any adult
8 who is otherwise eligible for assistance under the medical
9 assistance program. As used in this paragraph, "dental
10 services" means diagnostic, preventative, restorative, or
11 corrective procedures, including procedures and services for
12 the prevention and treatment of periodontal disease and dental
13 caries disease, provided by an individual who is licensed to
14 practice dentistry or dental surgery or who is under the
15 supervision of a dentist in the practice of his or her
16 profession.
17 On and after July 1, 2018, targeted dental services, as
18 set forth in Exhibit D of the Consent Decree entered by the
19 United States District Court for the Northern District of
20 Illinois, Eastern Division, in the matter of Memisovski v.
21 Maram, Case No. 92 C 1982, that are provided to adults under
22 the medical assistance program shall be established at no less
23 than the rates set forth in the "New Rate" column in Exhibit D
24 of the Consent Decree for targeted dental services that are
25 provided to persons under the age of 18 under the medical
26 assistance program.
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1 Subject to federal approval, on and after January 1, 2025,
2 the rates paid for sedation evaluation and the provision of
3 deep sedation and intravenous sedation for the purpose of
4 dental services shall be increased by 33% above the rates in
5 effect on December 31, 2024. The rates paid for nitrous oxide
6 sedation shall not be impacted by this paragraph and shall
7 remain the same as the rates in effect on December 31, 2024.
8 Notwithstanding any other provision of this Code and
9 subject to federal approval, the Department may adopt rules to
10 allow a dentist who is volunteering his or her service at no
11 cost to render dental services through an enrolled
12 not-for-profit health clinic without the dentist personally
13 enrolling as a participating provider in the medical
14 assistance program. A not-for-profit health clinic shall
15 include a public health clinic or Federally Qualified Health
16 Center or other enrolled provider, as determined by the
17 Department, through which dental services covered under this
18 Section are performed. The Department shall establish a
19 process for payment of claims for reimbursement for covered
20 dental services rendered under this provision.
21 Subject to appropriation and to federal approval, the
22 Department shall file administrative rules updating the
23 Handicapping Labio-Lingual Deviation orthodontic scoring tool
24 by January 1, 2025, or as soon as practicable.
25 On and after January 1, 2022, the Department of Healthcare
26 and Family Services shall administer and regulate a
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1 school-based dental program that allows for the out-of-office
2 delivery of preventative dental services in a school setting
3 to children under 19 years of age. The Department shall
4 establish, by rule, guidelines for participation by providers
5 and set requirements for follow-up referral care based on the
6 requirements established in the Dental Office Reference Manual
7 published by the Department that establishes the requirements
8 for dentists participating in the All Kids Dental School
9 Program. Every effort shall be made by the Department when
10 developing the program requirements to consider the different
11 geographic differences of both urban and rural areas of the
12 State for initial treatment and necessary follow-up care. No
13 provider shall be charged a fee by any unit of local government
14 to participate in the school-based dental program administered
15 by the Department. Nothing in this paragraph shall be
16 construed to limit or preempt a home rule unit's or school
17 district's authority to establish, change, or administer a
18 school-based dental program in addition to, or independent of,
19 the school-based dental program administered by the
20 Department.
21 The Illinois Department, by rule, may distinguish and
22 classify the medical services to be provided only in
23 accordance with the classes of persons designated in Section
24 5-2.
25 The Department of Healthcare and Family Services must
26 provide coverage and reimbursement for amino acid-based
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1 elemental formulas, regardless of delivery method, for the
2 diagnosis and treatment of (i) eosinophilic disorders and (ii)
3 short bowel syndrome when the prescribing physician has issued
4 a written order stating that the amino acid-based elemental
5 formula is medically necessary.
6 The Illinois Department shall authorize the provision of,
7 and shall authorize payment for, screening by low-dose
8 mammography for the presence of occult breast cancer for
9 individuals 35 years of age or older who are eligible for
10 medical assistance under this Article, as follows:
11 (A) A baseline mammogram for individuals 35 to 39
12 years of age.
13 (B) An annual mammogram for individuals 40 years of
14 age or older.
15 (C) A mammogram at the age and intervals considered
16 medically necessary by the individual's health care
17 provider for individuals under 40 years of age and having
18 a family history of breast cancer, prior personal history
19 of breast cancer, positive genetic testing, or other risk
20 factors.
21 (D) A comprehensive ultrasound screening and MRI of an
22 entire breast or breasts if a mammogram demonstrates
23 heterogeneous or dense breast tissue or when medically
24 necessary as determined by a physician licensed to
25 practice medicine in all of its branches.
26 (E) A screening MRI when medically necessary, as
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1 determined by a physician licensed to practice medicine in
2 all of its branches.
3 (F) A diagnostic mammogram when medically necessary,
4 as determined by a physician licensed to practice medicine
5 in all its branches, advanced practice registered nurse,
6 or physician assistant.
7 (G) Molecular breast imaging (MBI) and MRI of an
8 entire breast or breasts if a mammogram demonstrates
9 heterogeneous or dense breast tissue or when medically
10 necessary as determined by a physician licensed to
11 practice medicine in all of its branches, advanced
12 practice registered nurse, or physician assistant.
13 The Department shall not impose a deductible, coinsurance,
14 copayment, or any other cost-sharing requirement on the
15 coverage provided under this paragraph; except that this
16 sentence does not apply to coverage of diagnostic mammograms
17 to the extent such coverage would disqualify a high-deductible
18 health plan from eligibility for a health savings account
19 pursuant to Section 223 of the Internal Revenue Code (26
20 U.S.C. 223).
21 All screenings shall include a physical breast exam,
22 instruction on self-examination and information regarding the
23 frequency of self-examination and its value as a preventative
24 tool.
25 For purposes of this Section:
26 "Diagnostic mammogram" means a mammogram obtained using
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1 diagnostic mammography.
2 "Diagnostic mammography" means a method of screening that
3 is designed to evaluate an abnormality in a breast, including
4 an abnormality seen or suspected on a screening mammogram or a
5 subjective or objective abnormality otherwise detected in the
6 breast.
7 "Low-dose mammography" means the x-ray examination of the
8 breast using equipment dedicated specifically for mammography,
9 including the x-ray tube, filter, compression device, and
10 image receptor, with an average radiation exposure delivery of
11 less than one rad per breast for 2 views of an average size
12 breast. The term also includes digital mammography and
13 includes breast tomosynthesis.
14 "Breast tomosynthesis" means a radiologic procedure that
15 involves the acquisition of projection images over the
16 stationary breast to produce cross-sectional digital
17 three-dimensional images of the breast.
18 If, at any time, the Secretary of the United States
19 Department of Health and Human Services, or its successor
20 agency, promulgates rules or regulations to be published in
21 the Federal Register or publishes a comment in the Federal
22 Register or issues an opinion, guidance, or other action that
23 would require the State, pursuant to any provision of the
24 Patient Protection and Affordable Care Act (Public Law
25 111-148), including, but not limited to, 42 U.S.C.
26 18031(d)(3)(B) or any successor provision, to defray the cost
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1 of any coverage for breast tomosynthesis outlined in this
2 paragraph, then the requirement that an insurer cover breast
3 tomosynthesis is inoperative other than any such coverage
4 authorized under Section 1902 of the Social Security Act, 42
5 U.S.C. 1396a, and the State shall not assume any obligation
6 for the cost of coverage for breast tomosynthesis set forth in
7 this paragraph.
8 On and after January 1, 2016, the Department shall ensure
9 that all networks of care for adult clients of the Department
10 include access to at least one breast imaging Center of
11 Imaging Excellence as certified by the American College of
12 Radiology.
13 On and after January 1, 2012, providers participating in a
14 quality improvement program approved by the Department shall
15 be reimbursed for screening and diagnostic mammography at the
16 same rate as the Medicare program's rates, including the
17 increased reimbursement for digital mammography and, after
18 January 1, 2023 (the effective date of Public Act 102-1018),
19 breast tomosynthesis.
20 The Department shall convene an expert panel including
21 representatives of hospitals, free-standing mammography
22 facilities, and doctors, including radiologists, to establish
23 quality standards for mammography.
24 On and after January 1, 2017, providers participating in a
25 breast cancer treatment quality improvement program approved
26 by the Department shall be reimbursed for breast cancer
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1 treatment at a rate that is no lower than 95% of the Medicare
2 program's rates for the data elements included in the breast
3 cancer treatment quality program.
4 The Department shall convene an expert panel, including
5 representatives of hospitals, free-standing breast cancer
6 treatment centers, breast cancer quality organizations, and
7 doctors, including radiologists that are trained in all forms
8 of FDA-approved FDA approved breast imaging technologies,
9 breast surgeons, reconstructive breast surgeons, oncologists,
10 and primary care providers to establish quality standards for
11 breast cancer treatment.
12 Subject to federal approval, the Department shall
13 establish a rate methodology for mammography at federally
14 qualified health centers and other encounter-rate clinics.
15 These clinics or centers may also collaborate with other
16 hospital-based mammography facilities. By January 1, 2016, the
17 Department shall report to the General Assembly on the status
18 of the provision set forth in this paragraph.
19 The Department shall establish a methodology to remind
20 individuals who are age-appropriate for screening mammography,
21 but who have not received a mammogram within the previous 18
22 months, of the importance and benefit of screening
23 mammography. The Department shall work with experts in breast
24 cancer outreach and patient navigation to optimize these
25 reminders and shall establish a methodology for evaluating
26 their effectiveness and modifying the methodology based on the
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1 evaluation.
2 The Department shall establish a performance goal for
3 primary care providers with respect to their female patients
4 over age 40 receiving an annual mammogram. This performance
5 goal shall be used to provide additional reimbursement in the
6 form of a quality performance bonus to primary care providers
7 who meet that goal.
8 The Department shall devise a means of case-managing or
9 patient navigation for beneficiaries diagnosed with breast
10 cancer. This program shall initially operate as a pilot
11 program in areas of the State with the highest incidence of
12 mortality related to breast cancer. At least one pilot program
13 site shall be in the metropolitan Chicago area and at least one
14 site shall be outside the metropolitan Chicago area. On or
15 after July 1, 2016, the pilot program shall be expanded to
16 include one site in western Illinois, one site in southern
17 Illinois, one site in central Illinois, and 4 sites within
18 metropolitan Chicago. An evaluation of the pilot program shall
19 be carried out measuring health outcomes and cost of care for
20 those served by the pilot program compared to similarly
21 situated patients who are not served by the pilot program.
22 The Department shall require all networks of care to
23 develop a means either internally or by contract with experts
24 in navigation and community outreach to navigate cancer
25 patients to comprehensive care in a timely fashion. The
26 Department shall require all networks of care to include
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1 access for patients diagnosed with cancer to at least one
2 academic commission on cancer-accredited cancer program as an
3 in-network covered benefit.
4 The Department shall provide coverage and reimbursement
5 for a human papillomavirus (HPV) vaccine that is approved for
6 marketing by the federal Food and Drug Administration for all
7 persons between the ages of 9 and 45. Subject to federal
8 approval, the Department shall provide coverage and
9 reimbursement for a human papillomavirus (HPV) vaccine for
10 persons of the age of 46 and above who have been diagnosed with
11 cervical dysplasia with a high risk of recurrence or
12 progression. The Department shall disallow any
13 preauthorization requirements for the administration of the
14 human papillomavirus (HPV) vaccine.
15 On or after July 1, 2022, individuals who are otherwise
16 eligible for medical assistance under this Article shall
17 receive coverage for perinatal depression screenings for the
18 12-month period beginning on the last day of their pregnancy.
19 Medical assistance coverage under this paragraph shall be
20 conditioned on the use of a screening instrument approved by
21 the Department.
22 Any medical or health care provider shall immediately
23 recommend, to any pregnant individual who is being provided
24 prenatal services and is suspected of having a substance use
25 disorder as defined in the Substance Use Disorder Act,
26 referral to a local substance use disorder treatment program
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1 licensed by the Department of Human Services or to a licensed
2 hospital which provides substance abuse treatment services.
3 The Department of Healthcare and Family Services shall assure
4 coverage for the cost of treatment of the drug abuse or
5 addiction for pregnant recipients in accordance with the
6 Illinois Medicaid Program in conjunction with the Department
7 of Human Services.
8 All medical providers providing medical assistance to
9 pregnant individuals under this Code shall receive information
10 from the Department on the availability of services under any
11 program providing case management services for addicted
12 individuals, including information on appropriate referrals
13 for other social services that may be needed by addicted
14 individuals in addition to treatment for addiction.
15 The Illinois Department, in cooperation with the
16 Departments of Human Services (as successor to the Department
17 of Alcoholism and Substance Abuse) and Public Health, through
18 a public awareness campaign, may provide information
19 concerning treatment for alcoholism and drug abuse and
20 addiction, prenatal health care, and other pertinent programs
21 directed at reducing the number of drug-affected infants born
22 to recipients of medical assistance.
23 Neither the Department of Healthcare and Family Services
24 nor the Department of Human Services shall sanction the
25 recipient solely on the basis of the recipient's substance
26 abuse.
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1 The Illinois Department shall establish such regulations
2 governing the dispensing of health services under this Article
3 as it shall deem appropriate. The Department should seek the
4 advice of formal professional advisory committees appointed by
5 the Director of the Illinois Department for the purpose of
6 providing regular advice on policy and administrative matters,
7 information dissemination and educational activities for
8 medical and health care providers, and consistency in
9 procedures to the Illinois Department.
10 The Illinois Department may develop and contract with
11 Partnerships of medical providers to arrange medical services
12 for persons eligible under Section 5-2 of this Code.
13 Implementation of this Section may be by demonstration
14 projects in certain geographic areas. The Partnership shall be
15 represented by a sponsor organization. The Department, by
16 rule, shall develop qualifications for sponsors of
17 Partnerships. Nothing in this Section shall be construed to
18 require that the sponsor organization be a medical
19 organization.
20 The sponsor must negotiate formal written contracts with
21 medical providers for physician services, inpatient and
22 outpatient hospital care, home health services, treatment for
23 alcoholism and substance abuse, and other services determined
24 necessary by the Illinois Department by rule for delivery by
25 Partnerships. Physician services must include prenatal and
26 obstetrical care. The Illinois Department shall reimburse
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1 medical services delivered by Partnership providers to clients
2 in target areas according to provisions of this Article and
3 the Illinois Health Finance Reform Act, except that:
4 (1) Physicians participating in a Partnership and
5 providing certain services, which shall be determined by
6 the Illinois Department, to persons in areas covered by
7 the Partnership may receive an additional surcharge for
8 such services.
9 (2) The Department may elect to consider and negotiate
10 financial incentives to encourage the development of
11 Partnerships and the efficient delivery of medical care.
12 (3) Persons receiving medical services through
13 Partnerships may receive medical and case management
14 services above the level usually offered through the
15 medical assistance program.
16 Medical providers shall be required to meet certain
17 qualifications to participate in Partnerships to ensure the
18 delivery of high quality medical services. These
19 qualifications shall be determined by rule of the Illinois
20 Department and may be higher than qualifications for
21 participation in the medical assistance program. Partnership
22 sponsors may prescribe reasonable additional qualifications
23 for participation by medical providers, only with the prior
24 written approval of the Illinois Department.
25 Nothing in this Section shall limit the free choice of
26 practitioners, hospitals, and other providers of medical
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1 services by clients. In order to ensure patient freedom of
2 choice, the Illinois Department shall immediately promulgate
3 all rules and take all other necessary actions so that
4 provided services may be accessed from therapeutically
5 certified optometrists to the full extent of the Illinois
6 Optometric Practice Act of 1987 without discriminating between
7 service providers.
8 The Department shall apply for a waiver from the United
9 States Health Care Financing Administration to allow for the
10 implementation of Partnerships under this Section.
11 The Illinois Department shall require health care
12 providers to maintain records that document the medical care
13 and services provided to recipients of Medical Assistance
14 under this Article. Such records must be retained for a period
15 of not less than 6 years from the date of service or as
16 provided by applicable State law, whichever period is longer,
17 except that if an audit is initiated within the required
18 retention period then the records must be retained until the
19 audit is completed and every exception is resolved. The
20 Illinois Department shall require health care providers to
21 make available, when authorized by the patient, in writing,
22 the medical records in a timely fashion to other health care
23 providers who are treating or serving persons eligible for
24 Medical Assistance under this Article. All dispensers of
25 medical services shall be required to maintain and retain
26 business and professional records sufficient to fully and
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1 accurately document the nature, scope, details and receipt of
2 the health care provided to persons eligible for medical
3 assistance under this Code, in accordance with regulations
4 promulgated by the Illinois Department. The rules and
5 regulations shall require that proof of the receipt of
6 prescription drugs, dentures, prosthetic devices and
7 eyeglasses by eligible persons under this Section accompany
8 each claim for reimbursement submitted by the dispenser of
9 such medical services. No such claims for reimbursement shall
10 be approved for payment by the Illinois Department without
11 such proof of receipt, unless the Illinois Department shall
12 have put into effect and shall be operating a system of
13 post-payment audit and review which shall, on a sampling
14 basis, be deemed adequate by the Illinois Department to assure
15 that such drugs, dentures, prosthetic devices and eyeglasses
16 for which payment is being made are actually being received by
17 eligible recipients. Within 90 days after September 16, 1984
18 (the effective date of Public Act 83-1439), the Illinois
19 Department shall establish a current list of acquisition costs
20 for all prosthetic devices and any other items recognized as
21 medical equipment and supplies reimbursable under this Article
22 and shall update such list on a quarterly basis, except that
23 the acquisition costs of all prescription drugs shall be
24 updated no less frequently than every 30 days as required by
25 Section 5-5.12.
26 Notwithstanding any other law to the contrary, the
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1 Illinois Department shall, within 365 days after July 22, 2013
2 (the effective date of Public Act 98-104), establish
3 procedures to permit skilled care facilities licensed under
4 the Nursing Home Care Act to submit monthly billing claims for
5 reimbursement purposes. Following development of these
6 procedures, the Department shall, by July 1, 2016, test the
7 viability of the new system and implement any necessary
8 operational or structural changes to its information
9 technology platforms in order to allow for the direct
10 acceptance and payment of nursing home claims.
11 Notwithstanding any other law to the contrary, the
12 Illinois Department shall, within 365 days after August 15,
13 2014 (the effective date of Public Act 98-963), establish
14 procedures to permit ID/DD facilities licensed under the ID/DD
15 Community Care Act and MC/DD facilities licensed under the
16 MC/DD Act to submit monthly billing claims for reimbursement
17 purposes. Following development of these procedures, the
18 Department shall have an additional 365 days to test the
19 viability of the new system and to ensure that any necessary
20 operational or structural changes to its information
21 technology platforms are implemented.
22 The Illinois Department shall require all dispensers of
23 medical services, other than an individual practitioner or
24 group of practitioners, desiring to participate in the Medical
25 Assistance program established under this Article to disclose
26 all financial, beneficial, ownership, equity, surety or other
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1 interests in any and all firms, corporations, partnerships,
2 associations, business enterprises, joint ventures, agencies,
3 institutions or other legal entities providing any form of
4 health care services in this State under this Article.
5 The Illinois Department may require that all dispensers of
6 medical services desiring to participate in the medical
7 assistance program established under this Article disclose,
8 under such terms and conditions as the Illinois Department may
9 by rule establish, all inquiries from clients and attorneys
10 regarding medical bills paid by the Illinois Department, which
11 inquiries could indicate potential existence of claims or
12 liens for the Illinois Department.
13 Enrollment of a vendor shall be subject to a provisional
14 period and shall be conditional for one year. During the
15 period of conditional enrollment, the Department may terminate
16 the vendor's eligibility to participate in, or may disenroll
17 the vendor from, the medical assistance program without cause.
18 Unless otherwise specified, such termination of eligibility or
19 disenrollment is not subject to the Department's hearing
20 process. However, a disenrolled vendor may reapply without
21 penalty.
22 The Department has the discretion to limit the conditional
23 enrollment period for vendors based upon the category of risk
24 of the vendor.
25 Prior to enrollment and during the conditional enrollment
26 period in the medical assistance program, all vendors shall be
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1 subject to enhanced oversight, screening, and review based on
2 the risk of fraud, waste, and abuse that is posed by the
3 category of risk of the vendor. The Illinois Department shall
4 establish the procedures for oversight, screening, and review,
5 which may include, but need not be limited to: criminal and
6 financial background checks; fingerprinting; license,
7 certification, and authorization verifications; unscheduled or
8 unannounced site visits; database checks; prepayment audit
9 reviews; audits; payment caps; payment suspensions; and other
10 screening as required by federal or State law.
11 The Department shall define or specify the following: (i)
12 by provider notice, the "category of risk of the vendor" for
13 each type of vendor, which shall take into account the level of
14 screening applicable to a particular category of vendor under
15 federal law and regulations; (ii) by rule or provider notice,
16 the maximum length of the conditional enrollment period for
17 each category of risk of the vendor; and (iii) by rule, the
18 hearing rights, if any, afforded to a vendor in each category
19 of risk of the vendor that is terminated or disenrolled during
20 the conditional enrollment period.
21 To be eligible for payment consideration, a vendor's
22 payment claim or bill, either as an initial claim or as a
23 resubmitted claim following prior rejection, must be received
24 by the Illinois Department, or its fiscal intermediary, no
25 later than 180 days after the latest date on the claim on which
26 medical goods or services were provided, with the following
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1 exceptions:
2 (1) In the case of a provider whose enrollment is in
3 process by the Illinois Department, the 180-day period
4 shall not begin until the date on the written notice from
5 the Illinois Department that the provider enrollment is
6 complete.
7 (2) In the case of errors attributable to the Illinois
8 Department or any of its claims processing intermediaries
9 which result in an inability to receive, process, or
10 adjudicate a claim, the 180-day period shall not begin
11 until the provider has been notified of the error.
12 (3) In the case of a provider for whom the Illinois
13 Department initiates the monthly billing process.
14 (4) In the case of a provider operated by a unit of
15 local government with a population exceeding 3,000,000
16 when local government funds finance federal participation
17 for claims payments.
18 For claims for services rendered during a period for which
19 a recipient received retroactive eligibility, claims must be
20 filed within 180 days after the Department determines the
21 applicant is eligible. For claims for which the Illinois
22 Department is not the primary payer, claims must be submitted
23 to the Illinois Department within 180 days after the final
24 adjudication by the primary payer.
25 In the case of long term care facilities, within 120
26 calendar days of receipt by the facility of required
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1 prescreening information, new admissions with associated
2 admission documents shall be submitted through the Medical
3 Electronic Data Interchange (MEDI) or the Recipient
4 Eligibility Verification (REV) System or shall be submitted
5 directly to the Department of Human Services using required
6 admission forms. Effective September 1, 2014, admission
7 documents, including all prescreening information, must be
8 submitted through MEDI or REV. Confirmation numbers assigned
9 to an accepted transaction shall be retained by a facility to
10 verify timely submittal. Once an admission transaction has
11 been completed, all resubmitted claims following prior
12 rejection are subject to receipt no later than 180 days after
13 the admission transaction has been completed.
14 Claims that are not submitted and received in compliance
15 with the foregoing requirements shall not be eligible for
16 payment under the medical assistance program, and the State
17 shall have no liability for payment of those claims.
18 To the extent consistent with applicable information and
19 privacy, security, and disclosure laws, State and federal
20 agencies and departments shall provide the Illinois Department
21 access to confidential and other information and data
22 necessary to perform eligibility and payment verifications and
23 other Illinois Department functions. This includes, but is not
24 limited to: information pertaining to licensure;
25 certification; earnings; immigration status; citizenship; wage
26 reporting; unearned and earned income; pension income;
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1 employment; supplemental security income; social security
2 numbers; National Provider Identifier (NPI) numbers; the
3 National Practitioner Data Bank (NPDB); program and agency
4 exclusions; taxpayer identification numbers; tax delinquency;
5 corporate information; and death records.
6 The Illinois Department shall enter into agreements with
7 State agencies and departments, and is authorized to enter
8 into agreements with federal agencies and departments, under
9 which such agencies and departments shall share data necessary
10 for medical assistance program integrity functions and
11 oversight. The Illinois Department shall develop, in
12 cooperation with other State departments and agencies, and in
13 compliance with applicable federal laws and regulations,
14 appropriate and effective methods to share such data. At a
15 minimum, and to the extent necessary to provide data sharing,
16 the Illinois Department shall enter into agreements with State
17 agencies and departments, and is authorized to enter into
18 agreements with federal agencies and departments, including,
19 but not limited to: the Secretary of State; the Department of
20 Revenue; the Department of Public Health; the Department of
21 Human Services; and the Department of Financial and
22 Professional Regulation.
23 Beginning in fiscal year 2013, the Illinois Department
24 shall set forth a request for information to identify the
25 benefits of a pre-payment, post-adjudication, and post-edit
26 claims system with the goals of streamlining claims processing
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1 and provider reimbursement, reducing the number of pending or
2 rejected claims, and helping to ensure a more transparent
3 adjudication process through the utilization of: (i) provider
4 data verification and provider screening technology; and (ii)
5 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
6 post-adjudicated predictive modeling with an integrated case
7 management system with link analysis. Such a request for
8 information shall not be considered as a request for proposal
9 or as an obligation on the part of the Illinois Department to
10 take any action or acquire any products or services.
11 The Illinois Department shall establish policies,
12 procedures, standards and criteria by rule for the
13 acquisition, repair and replacement of orthotic and prosthetic
14 devices and durable medical equipment. Such rules shall
15 provide, but not be limited to, the following services: (1)
16 immediate repair or replacement of such devices by recipients;
17 and (2) rental, lease, purchase or lease-purchase of durable
18 medical equipment in a cost-effective manner, taking into
19 consideration the recipient's medical prognosis, the extent of
20 the recipient's needs, and the requirements and costs for
21 maintaining such equipment. Subject to prior approval, such
22 rules shall enable a recipient to temporarily acquire and use
23 alternative or substitute devices or equipment pending repairs
24 or replacements of any device or equipment previously
25 authorized for such recipient by the Department.
26 Notwithstanding any provision of Section 5-5f to the contrary,
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1 the Department may, by rule, exempt certain replacement
2 wheelchair parts from prior approval and, for wheelchairs,
3 wheelchair parts, wheelchair accessories, and related seating
4 and positioning items, determine the wholesale price by
5 methods other than actual acquisition costs.
6 The Department shall require, by rule, all providers of
7 durable medical equipment to be accredited by an accreditation
8 organization approved by the federal Centers for Medicare and
9 Medicaid Services and recognized by the Department in order to
10 bill the Department for providing durable medical equipment to
11 recipients. No later than 15 months after the effective date
12 of the rule adopted pursuant to this paragraph, all providers
13 must meet the accreditation requirement.
14 In order to promote environmental responsibility, meet the
15 needs of recipients and enrollees, and achieve significant
16 cost savings, the Department, or a managed care organization
17 under contract with the Department, may provide recipients or
18 managed care enrollees who have a prescription or Certificate
19 of Medical Necessity access to refurbished durable medical
20 equipment under this Section (excluding prosthetic and
21 orthotic devices as defined in the Orthotics, Prosthetics, and
22 Pedorthics Practice Act and complex rehabilitation technology
23 products and associated services) through the State's
24 assistive technology program's reutilization program, using
25 staff with the Assistive Technology Professional (ATP)
26 Certification if the refurbished durable medical equipment:
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1 (i) is available; (ii) is less expensive, including shipping
2 costs, than new durable medical equipment of the same type;
3 (iii) is able to withstand at least 3 years of use; (iv) is
4 cleaned, disinfected, sterilized, and safe in accordance with
5 federal Food and Drug Administration regulations and guidance
6 governing the reprocessing of medical devices in health care
7 settings; and (v) equally meets the needs of the recipient or
8 enrollee. The reutilization program shall confirm that the
9 recipient or enrollee is not already in receipt of the same or
10 similar equipment from another service provider, and that the
11 refurbished durable medical equipment equally meets the needs
12 of the recipient or enrollee. Nothing in this paragraph shall
13 be construed to limit recipient or enrollee choice to obtain
14 new durable medical equipment or place any additional prior
15 authorization conditions on enrollees of managed care
16 organizations.
17 The Department shall execute, relative to the nursing home
18 prescreening project, written inter-agency agreements with the
19 Department of Human Services and the Department on Aging, to
20 effect the following: (i) intake procedures and common
21 eligibility criteria for those persons who are receiving
22 non-institutional services; and (ii) the establishment and
23 development of non-institutional services in areas of the
24 State where they are not currently available or are
25 undeveloped; and (iii) notwithstanding any other provision of
26 law, subject to federal approval, on and after July 1, 2012, an
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1 increase in the determination of need (DON) scores from 29 to
2 37 for applicants for institutional and home and
3 community-based long term care; if and only if federal
4 approval is not granted, the Department may, in conjunction
5 with other affected agencies, implement utilization controls
6 or changes in benefit packages to effectuate a similar savings
7 amount for this population; and (iv) no later than July 1,
8 2013, minimum level of care eligibility criteria for
9 institutional and home and community-based long term care; and
10 (v) no later than October 1, 2013, establish procedures to
11 permit long term care providers access to eligibility scores
12 for individuals with an admission date who are seeking or
13 receiving services from the long term care provider. In order
14 to select the minimum level of care eligibility criteria, the
15 Governor shall establish a workgroup that includes affected
16 agency representatives and stakeholders representing the
17 institutional and home and community-based long term care
18 interests. This Section shall not restrict the Department from
19 implementing lower level of care eligibility criteria for
20 community-based services in circumstances where federal
21 approval has been granted.
22 The Illinois Department shall develop and operate, in
23 cooperation with other State Departments and agencies and in
24 compliance with applicable federal laws and regulations,
25 appropriate and effective systems of health care evaluation
26 and programs for monitoring of utilization of health care
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1 services and facilities, as it affects persons eligible for
2 medical assistance under this Code.
3 The Illinois Department shall report annually to the
4 General Assembly, no later than the second Friday in April of
5 1979 and each year thereafter, in regard to:
6 (a) actual statistics and trends in utilization of
7 medical services by public aid recipients;
8 (b) actual statistics and trends in the provision of
9 the various medical services by medical vendors;
10 (c) current rate structures and proposed changes in
11 those rate structures for the various medical vendors; and
12 (d) efforts at utilization review and control by the
13 Illinois Department.
14 The period covered by each report shall be the 3 years
15 ending on the June 30 prior to the report. The report shall
16 include suggested legislation for consideration by the General
17 Assembly. The requirement for reporting to the General
18 Assembly shall be satisfied by filing copies of the report as
19 required by Section 3.1 of the General Assembly Organization
20 Act, and filing such additional copies with the State
21 Government Report Distribution Center for the General Assembly
22 as is required under paragraph (t) of Section 7 of the State
23 Library Act.
24 Rulemaking authority to implement Public Act 95-1045, if
25 any, is conditioned on the rules being adopted in accordance
26 with all provisions of the Illinois Administrative Procedure
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1 Act and all rules and procedures of the Joint Committee on
2 Administrative Rules; any purported rule not so adopted, for
3 whatever reason, is unauthorized.
4 On and after July 1, 2012, the Department shall reduce any
5 rate of reimbursement for services or other payments or alter
6 any methodologies authorized by this Code to reduce any rate
7 of reimbursement for services or other payments in accordance
8 with Section 5-5e.
9 Because kidney transplantation can be an appropriate,
10 cost-effective alternative to renal dialysis when medically
11 necessary and notwithstanding the provisions of Section 1-11
12 of this Code, beginning October 1, 2014, the Department shall
13 cover kidney transplantation for noncitizens with end-stage
14 renal disease who are not eligible for comprehensive medical
15 benefits, who meet the residency requirements of Section 5-3
16 of this Code, and who would otherwise meet the financial
17 requirements of the appropriate class of eligible persons
18 under Section 5-2 of this Code. To qualify for coverage of
19 kidney transplantation, such person must be receiving
20 emergency renal dialysis services covered by the Department.
21 Providers under this Section shall be prior approved and
22 certified by the Department to perform kidney transplantation
23 and the services under this Section shall be limited to
24 services associated with kidney transplantation.
25 Notwithstanding any other provision of this Code to the
26 contrary, on or after July 1, 2015, all FDA-approved FDA
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1 approved forms of medication assisted treatment prescribed for
2 the treatment of alcohol dependence or treatment of opioid
3 dependence shall be covered under both fee-for-service and
4 managed care medical assistance programs for persons who are
5 otherwise eligible for medical assistance under this Article
6 and shall not be subject to any (1) utilization control, other
7 than those established under the American Society of Addiction
8 Medicine patient placement criteria, (2) prior authorization
9 mandate, (3) lifetime restriction limit mandate, or (4)
10 limitations on dosage.
11 On or after July 1, 2015, opioid antagonists prescribed
12 for the treatment of an opioid overdose, including the
13 medication product, administration devices, and any pharmacy
14 fees or hospital fees related to the dispensing, distribution,
15 and administration of the opioid antagonist, shall be covered
16 under the medical assistance program for persons who are
17 otherwise eligible for medical assistance under this Article.
18 As used in this Section, "opioid antagonist" means a drug that
19 binds to opioid receptors and blocks or inhibits the effect of
20 opioids acting on those receptors, including, but not limited
21 to, naloxone hydrochloride or any other similarly acting drug
22 approved by the U.S. Food and Drug Administration. The
23 Department shall not impose a copayment on the coverage
24 provided for naloxone hydrochloride under the medical
25 assistance program.
26 Upon federal approval, the Department shall provide
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1 coverage and reimbursement for all drugs that are approved for
2 marketing by the federal Food and Drug Administration and that
3 are recommended by the federal Public Health Service or the
4 United States Centers for Disease Control and Prevention for
5 pre-exposure prophylaxis and related pre-exposure prophylaxis
6 services, including, but not limited to, HIV and sexually
7 transmitted infection screening, treatment for sexually
8 transmitted infections, medical monitoring, assorted labs, and
9 counseling to reduce the likelihood of HIV infection among
10 individuals who are not infected with HIV but who are at high
11 risk of HIV infection.
12 A federally qualified health center, as defined in Section
13 1905(l)(2)(B) of the federal Social Security Act, shall be
14 reimbursed by the Department in accordance with the federally
15 qualified health center's encounter rate for services provided
16 to medical assistance recipients that are performed by a
17 dental hygienist, as defined under the Illinois Dental
18 Practice Act, working under the general supervision of a
19 dentist and employed by a federally qualified health center.
20 Within 90 days after October 8, 2021 (the effective date
21 of Public Act 102-665), the Department shall seek federal
22 approval of a State Plan amendment to expand coverage for
23 family planning services that includes presumptive eligibility
24 to individuals whose income is at or below 208% of the federal
25 poverty level. Coverage under this Section shall be effective
26 beginning no later than December 1, 2022.
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1 Subject to approval by the federal Centers for Medicare
2 and Medicaid Services of a Title XIX State Plan amendment
3 electing the Program of All-Inclusive Care for the Elderly
4 (PACE) as a State Medicaid option, as provided for by Subtitle
5 I (commencing with Section 4801) of Title IV of the Balanced
6 Budget Act of 1997 (Public Law 105-33) and Part 460
7 (commencing with Section 460.2) of Subchapter E of Title 42 of
8 the Code of Federal Regulations, PACE program services shall
9 become a covered benefit of the medical assistance program,
10 subject to criteria established in accordance with all
11 applicable laws.
12 Notwithstanding any other provision of this Code,
13 community-based pediatric palliative care from a trained
14 interdisciplinary team shall be covered under the medical
15 assistance program as provided in Section 15 of the Pediatric
16 Palliative Care Act.
17 Notwithstanding any other provision of this Code, within
18 12 months after June 2, 2022 (the effective date of Public Act
19 102-1037) and subject to federal approval, acupuncture
20 services performed by an acupuncturist licensed under the
21 Acupuncture Practice Act who is acting within the scope of his
22 or her license shall be covered under the medical assistance
23 program. The Department shall apply for any federal waiver or
24 State Plan amendment, if required, to implement this
25 paragraph. The Department may adopt any rules, including
26 standards and criteria, necessary to implement this paragraph.
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1 Notwithstanding any other provision of this Code, the
2 medical assistance program shall, subject to federal approval,
3 reimburse hospitals for costs associated with a newborn
4 screening test for the presence of metachromatic
5 leukodystrophy, as required under the Newborn Metabolic
6 Screening Act, at a rate not less than the fee charged by the
7 Department of Public Health. Notwithstanding any other
8 provision of this Code, the medical assistance program shall,
9 subject to appropriation and federal approval, also reimburse
10 hospitals for costs associated with all newborn screening
11 tests added on and after August 9, 2024 (the effective date of
12 Public Act 103-909) this amendatory Act of the 103rd General
13 Assembly to the Newborn Metabolic Screening Act and required
14 to be performed under that Act at a rate not less than the fee
15 charged by the Department of Public Health. The Department
16 shall seek federal approval before the implementation of the
17 newborn screening test fees by the Department of Public
18 Health.
19 Notwithstanding any other provision of this Code,
20 beginning on January 1, 2024, subject to federal approval,
21 cognitive assessment and care planning services provided to a
22 person who experiences signs or symptoms of cognitive
23 impairment, as defined by the Diagnostic and Statistical
24 Manual of Mental Disorders, Fifth Edition, shall be covered
25 under the medical assistance program for persons who are
26 otherwise eligible for medical assistance under this Article.
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1 Notwithstanding any other provision of this Code,
2 medically necessary reconstructive services that are intended
3 to restore physical appearance shall be covered under the
4 medical assistance program for persons who are otherwise
5 eligible for medical assistance under this Article. As used in
6 this paragraph, "reconstructive services" means treatments
7 performed on structures of the body damaged by trauma to
8 restore physical appearance.
9 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
10 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
11 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
12 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
13 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
14 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
15 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
16 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
17 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
18 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
19 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
20 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
21 8-9-24; revised 10-10-24.)
22 (305 ILCS 5/12-4.35)
23 Sec. 12-4.35. Medical services for certain noncitizens.
24 (a) Notwithstanding Section 1-11 of this Code or Section 20(a)
25 of the Children's Health Insurance Program Act, the Department
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1 of Healthcare and Family Services may provide medical services
2 to noncitizens who have not yet attained 19 years of age and
3 who are not eligible for medical assistance under Article V of
4 this Code or under the Children's Health Insurance Program
5 created by the Children's Health Insurance Program Act due to
6 their not meeting the otherwise applicable provisions of
7 Section 1-11 of this Code or Section 20(a) of the Children's
8 Health Insurance Program Act. The medical services available,
9 standards for eligibility, and other conditions of
10 participation under this Section shall be established by rule
11 by the Department; however, any such rule shall be at least as
12 restrictive as the rules for medical assistance under Article
13 V of this Code or the Children's Health Insurance Program
14 created by the Children's Health Insurance Program Act.
15 (a-5) Notwithstanding Section 1-11 of this Code, the
16 Department of Healthcare and Family Services may provide
17 medical assistance in accordance with Article V of this Code
18 to noncitizens over the age of 65 years of age who are not
19 eligible for medical assistance under Article V of this Code
20 due to their not meeting the otherwise applicable provisions
21 of Section 1-11 of this Code, whose income is at or below 100%
22 of the federal poverty level after deducting the costs of
23 medical or other remedial care, and who would otherwise meet
24 the eligibility requirements in Section 5-2 of this Code. The
25 medical services available, standards for eligibility, and
26 other conditions of participation under this Section shall be
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1 established by rule by the Department; however, any such rule
2 shall be at least as restrictive as the rules for medical
3 assistance under Article V of this Code.
4 (a-6) By May 30, 2022, notwithstanding Section 1-11 of
5 this Code, the Department of Healthcare and Family Services
6 may provide medical services to noncitizens 55 years of age
7 through 64 years of age who (i) are not eligible for medical
8 assistance under Article V of this Code due to their not
9 meeting the otherwise applicable provisions of Section 1-11 of
10 this Code and (ii) have income at or below 133% of the federal
11 poverty level plus 5% for the applicable family size as
12 determined under applicable federal law and regulations.
13 Persons eligible for medical services under Public Act 102-16
14 shall receive benefits identical to the benefits provided
15 under the Health Benefits Service Package as that term is
16 defined in subsection (m) of Section 5-1.1 of this Code.
17 (a-7) By July 1, 2022, notwithstanding Section 1-11 of
18 this Code, the Department of Healthcare and Family Services
19 may provide medical services to noncitizens 42 years of age
20 through 54 years of age who (i) are not eligible for medical
21 assistance under Article V of this Code due to their not
22 meeting the otherwise applicable provisions of Section 1-11 of
23 this Code and (ii) have income at or below 133% of the federal
24 poverty level plus 5% for the applicable family size as
25 determined under applicable federal law and regulations. The
26 medical services available, standards for eligibility, and
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1 other conditions of participation under this Section shall be
2 established by rule by the Department; however, any such rule
3 shall be at least as restrictive as the rules for medical
4 assistance under Article V of this Code. In order to provide
5 for the timely and expeditious implementation of this
6 subsection, the Department may adopt rules necessary to
7 establish and implement this subsection through the use of
8 emergency rulemaking in accordance with Section 5-45 of the
9 Illinois Administrative Procedure Act. For purposes of the
10 Illinois Administrative Procedure Act, the General Assembly
11 finds that the adoption of rules to implement this subsection
12 is deemed necessary for the public interest, safety, and
13 welfare.
14 (a-10) Notwithstanding the provisions of Section 1-11, the
15 Department shall cover immunosuppressive drugs and related
16 services associated with post-kidney transplant management,
17 excluding long-term care costs, for noncitizens who: (i) are
18 not eligible for comprehensive medical benefits; (ii) meet the
19 residency requirements of Section 5-3; and (iii) would meet
20 the financial eligibility requirements of Section 5-2.
21 (b) The Department is authorized to take any action that
22 would not otherwise be prohibited by applicable law,
23 including, without limitation, cessation or limitation of
24 enrollment, reduction of available medical services, and
25 changing standards for eligibility, that is deemed necessary
26 by the Department during a State fiscal year to assure that
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1 payments under this Section do not exceed available funds.
2 (c) (Blank).
3 (d) (Blank).
4 (e) In order to provide for the expeditious and effective
5 ongoing implementation of this Section, the Department may
6 adopt rules through the use of emergency rulemaking in
7 accordance with Section 5-45 of the Illinois Administrative
8 Procedure Act, except that the limitation on the number of
9 emergency rules that may be adopted in a 24-month period shall
10 not apply. For purposes of the Illinois Administrative
11 Procedure Act, the General Assembly finds that the adoption of
12 rules to implement this Section is deemed necessary for the
13 public interest, safety, and welfare. This subsection (e) is
14 inoperative on and after July 1, 2025.
15 (Source: P.A. 102-16, eff. 6-17-21; 102-43, Article 25,
16 Section 25-15, eff. 7-6-21; 102-43, Article 45, Section 45-5,
17 eff. 7-6-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22;
18 103-102, eff. 6-16-23.)
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