Illinois 2025-2026 Regular Session

Illinois House Bill HB1504 Compare Versions

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

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1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1504 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that no later than July 1, 2025, over-the-counter choline dietary supplements for pregnant persons shall be covered under the medical assistance program. Effective immediately. LRB104 08529 KTG 18581 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1504 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that no later than July 1, 2025, over-the-counter choline dietary supplements for pregnant persons shall be covered under the medical assistance program. Effective immediately. LRB104 08529 KTG 18581 b LRB104 08529 KTG 18581 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1504 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 305 ILCS 5/5-5
4	4	305 ILCS 5/5-5
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that no later than July 1, 2025, over-the-counter choline dietary supplements for pregnant persons shall be covered under the medical assistance program. Effective immediately.
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8	8	A BILL FOR
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11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5 as follows:
16	16	6 (305 ILCS 5/5-5)
17	17	7 (Text of Section before amendment by P.A. 103-808)
18	18	8 Sec. 5-5. Medical services. The Illinois Department, by
19	19	9 rule, shall determine the quantity and quality of and the rate
20	20	10 of reimbursement for the medical assistance for which payment
21	21	11 will be authorized, and the medical services to be provided,
22	22	12 which may include all or part of the following: (1) inpatient
23	23	13 hospital services; (2) outpatient hospital services; (3) other
24	24	14 laboratory and X-ray services; (4) skilled nursing home
25	25	15 services; (5) physicians' services whether furnished in the
26	26	16 office, the patient's home, a hospital, a skilled nursing
27	27	17 home, or elsewhere; (6) medical care, or any other type of
28	28	18 remedial care furnished by licensed practitioners; (7) home
29	29	19 health care services; (8) private duty nursing service; (9)
30	30	20 clinic services; (10) dental services, including prevention
31	31	21 and treatment of periodontal disease and dental caries disease
32	32	22 for pregnant individuals, provided by an individual licensed
33	33	23 to practice dentistry or dental surgery; for purposes of this
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37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1504 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5 305 ILCS 5/5-5
39	39	305 ILCS 5/5-5
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that no later than July 1, 2025, over-the-counter choline dietary supplements for pregnant persons shall be covered under the medical assistance program. Effective immediately.
41	41	LRB104 08529 KTG 18581 b LRB104 08529 KTG 18581 b
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43	43	A BILL FOR
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68	68	1 item (10), "dental services" means diagnostic, preventive, or
69	69	2 corrective procedures provided by or under the supervision of
70	70	3 a dentist in the practice of his or her profession; (11)
71	71	4 physical therapy and related services; (12) prescribed drugs,
72	72	5 dentures, and prosthetic devices; and eyeglasses prescribed by
73	73	6 a physician skilled in the diseases of the eye, or by an
74	74	7 optometrist, whichever the person may select; (13) other
75	75	8 diagnostic, screening, preventive, and rehabilitative
76	76	9 services, including to ensure that the individual's need for
77	77	10 intervention or treatment of mental disorders or substance use
78	78	11 disorders or co-occurring mental health and substance use
79	79	12 disorders is determined using a uniform screening, assessment,
80	80	13 and evaluation process inclusive of criteria, for children and
81	81	14 adults; for purposes of this item (13), a uniform screening,
82	82	15 assessment, and evaluation process refers to a process that
83	83	16 includes an appropriate evaluation and, as warranted, a
84	84	17 referral; "uniform" does not mean the use of a singular
85	85	18 instrument, tool, or process that all must utilize; (14)
86	86	19 transportation and such other expenses as may be necessary;
87	87	20 (15) medical treatment of sexual assault survivors, as defined
88	88	21 in Section 1a of the Sexual Assault Survivors Emergency
89	89	22 Treatment Act, for injuries sustained as a result of the
90	90	23 sexual assault, including examinations and laboratory tests to
91	91	24 discover evidence which may be used in criminal proceedings
92	92	25 arising from the sexual assault; (16) the diagnosis and
93	93	26 treatment of sickle cell anemia; (16.5) services performed by
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104	104	1 a chiropractic physician licensed under the Medical Practice
105	105	2 Act of 1987 and acting within the scope of his or her license,
106	106	3 including, but not limited to, chiropractic manipulative
107	107	4 treatment; and (17) any other medical care, and any other type
108	108	5 of remedial care recognized under the laws of this State. The
109	109	6 term "any other type of remedial care" shall include nursing
110	110	7 care and nursing home service for persons who rely on
111	111	8 treatment by spiritual means alone through prayer for healing.
112	112	9 Notwithstanding any other provision of this Section, a
113	113	10 comprehensive tobacco use cessation program that includes
114	114	11 purchasing prescription drugs or prescription medical devices
115	115	12 approved by the Food and Drug Administration shall be covered
116	116	13 under the medical assistance program under this Article for
117	117	14 persons who are otherwise eligible for assistance under this
118	118	15 Article.
119	119	16 Notwithstanding any other provision of this Code,
120	120	17 reproductive health care that is otherwise legal in Illinois
121	121	18 shall be covered under the medical assistance program for
122	122	19 persons who are otherwise eligible for medical assistance
123	123	20 under this Article.
124	124	21 Notwithstanding any other provision of this Section, all
125	125	22 tobacco cessation medications approved by the United States
126	126	23 Food and Drug Administration and all individual and group
127	127	24 tobacco cessation counseling services and telephone-based
128	128	25 counseling services and tobacco cessation medications provided
129	129	26 through the Illinois Tobacco Quitline shall be covered under
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140	140	1 the medical assistance program for persons who are otherwise
141	141	2 eligible for assistance under this Article. The Department
142	142	3 shall comply with all federal requirements necessary to obtain
143	143	4 federal financial participation, as specified in 42 CFR
144	144	5 433.15(b)(7), for telephone-based counseling services provided
145	145	6 through the Illinois Tobacco Quitline, including, but not
146	146	7 limited to: (i) entering into a memorandum of understanding or
147	147	8 interagency agreement with the Department of Public Health, as
148	148	9 administrator of the Illinois Tobacco Quitline; and (ii)
149	149	10 developing a cost allocation plan for Medicaid-allowable
150	150	11 Illinois Tobacco Quitline services in accordance with 45 CFR
151	151	12 95.507. The Department shall submit the memorandum of
152	152	13 understanding or interagency agreement, the cost allocation
153	153	14 plan, and all other necessary documentation to the Centers for
154	154	15 Medicare and Medicaid Services for review and approval.
155	155	16 Coverage under this paragraph shall be contingent upon federal
156	156	17 approval.
157	157	18 Notwithstanding any other provision of this Code, the
158	158	19 Illinois Department may not require, as a condition of payment
159	159	20 for any laboratory test authorized under this Article, that a
160	160	21 physician's handwritten signature appear on the laboratory
161	161	22 test order form. The Illinois Department may, however, impose
162	162	23 other appropriate requirements regarding laboratory test order
163	163	24 documentation.
164	164	25 Upon receipt of federal approval of an amendment to the
165	165	26 Illinois Title XIX State Plan for this purpose, the Department
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176	176	1 shall authorize the Chicago Public Schools (CPS) to procure a
177	177	2 vendor or vendors to manufacture eyeglasses for individuals
178	178	3 enrolled in a school within the CPS system. CPS shall ensure
179	179	4 that its vendor or vendors are enrolled as providers in the
180	180	5 medical assistance program and in any capitated Medicaid
181	181	6 managed care entity (MCE) serving individuals enrolled in a
182	182	7 school within the CPS system. Under any contract procured
183	183	8 under this provision, the vendor or vendors must serve only
184	184	9 individuals enrolled in a school within the CPS system. Claims
185	185	10 for services provided by CPS's vendor or vendors to recipients
186	186	11 of benefits in the medical assistance program under this Code,
187	187	12 the Children's Health Insurance Program, or the Covering ALL
188	188	13 KIDS Health Insurance Program shall be submitted to the
189	189	14 Department or the MCE in which the individual is enrolled for
190	190	15 payment and shall be reimbursed at the Department's or the
191	191	16 MCE's established rates or rate methodologies for eyeglasses.
192	192	17 On and after July 1, 2012, the Department of Healthcare
193	193	18 and Family Services may provide the following services to
194	194	19 persons eligible for assistance under this Article who are
195	195	20 participating in education, training or employment programs
196	196	21 operated by the Department of Human Services as successor to
197	197	22 the Department of Public Aid:
198	198	23 (1) dental services provided by or under the
199	199	24 supervision of a dentist; and
200	200	25 (2) eyeglasses prescribed by a physician skilled in
201	201	26 the diseases of the eye, or by an optometrist, whichever
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212	212	1 the person may select.
213	213	2 On and after July 1, 2018, the Department of Healthcare
214	214	3 and Family Services shall provide dental services to any adult
215	215	4 who is otherwise eligible for assistance under the medical
216	216	5 assistance program. As used in this paragraph, "dental
217	217	6 services" means diagnostic, preventative, restorative, or
218	218	7 corrective procedures, including procedures and services for
219	219	8 the prevention and treatment of periodontal disease and dental
220	220	9 caries disease, provided by an individual who is licensed to
221	221	10 practice dentistry or dental surgery or who is under the
222	222	11 supervision of a dentist in the practice of his or her
223	223	12 profession.
224	224	13 On and after July 1, 2018, targeted dental services, as
225	225	14 set forth in Exhibit D of the Consent Decree entered by the
226	226	15 United States District Court for the Northern District of
227	227	16 Illinois, Eastern Division, in the matter of Memisovski v.
228	228	17 Maram, Case No. 92 C 1982, that are provided to adults under
229	229	18 the medical assistance program shall be established at no less
230	230	19 than the rates set forth in the "New Rate" column in Exhibit D
231	231	20 of the Consent Decree for targeted dental services that are
232	232	21 provided to persons under the age of 18 under the medical
233	233	22 assistance program.
234	234	23 Subject to federal approval, on and after January 1, 2025,
235	235	24 the rates paid for sedation evaluation and the provision of
236	236	25 deep sedation and intravenous sedation for the purpose of
237	237	26 dental services shall be increased by 33% above the rates in
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248	248	1 effect on December 31, 2024. The rates paid for nitrous oxide
249	249	2 sedation shall not be impacted by this paragraph and shall
250	250	3 remain the same as the rates in effect on December 31, 2024.
251	251	4 Notwithstanding any other provision of this Code and
252	252	5 subject to federal approval, the Department may adopt rules to
253	253	6 allow a dentist who is volunteering his or her service at no
254	254	7 cost to render dental services through an enrolled
255	255	8 not-for-profit health clinic without the dentist personally
256	256	9 enrolling as a participating provider in the medical
257	257	10 assistance program. A not-for-profit health clinic shall
258	258	11 include a public health clinic or Federally Qualified Health
259	259	12 Center or other enrolled provider, as determined by the
260	260	13 Department, through which dental services covered under this
261	261	14 Section are performed. The Department shall establish a
262	262	15 process for payment of claims for reimbursement for covered
263	263	16 dental services rendered under this provision.
264	264	17 Subject to appropriation and to federal approval, the
265	265	18 Department shall file administrative rules updating the
266	266	19 Handicapping Labio-Lingual Deviation orthodontic scoring tool
267	267	20 by January 1, 2025, or as soon as practicable.
268	268	21 On and after January 1, 2022, the Department of Healthcare
269	269	22 and Family Services shall administer and regulate a
270	270	23 school-based dental program that allows for the out-of-office
271	271	24 delivery of preventative dental services in a school setting
272	272	25 to children under 19 years of age. The Department shall
273	273	26 establish, by rule, guidelines for participation by providers
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284	284	1 and set requirements for follow-up referral care based on the
285	285	2 requirements established in the Dental Office Reference Manual
286	286	3 published by the Department that establishes the requirements
287	287	4 for dentists participating in the All Kids Dental School
288	288	5 Program. Every effort shall be made by the Department when
289	289	6 developing the program requirements to consider the different
290	290	7 geographic differences of both urban and rural areas of the
291	291	8 State for initial treatment and necessary follow-up care. No
292	292	9 provider shall be charged a fee by any unit of local government
293	293	10 to participate in the school-based dental program administered
294	294	11 by the Department. Nothing in this paragraph shall be
295	295	12 construed to limit or preempt a home rule unit's or school
296	296	13 district's authority to establish, change, or administer a
297	297	14 school-based dental program in addition to, or independent of,
298	298	15 the school-based dental program administered by the
299	299	16 Department.
300	300	17 The Illinois Department, by rule, may distinguish and
301	301	18 classify the medical services to be provided only in
302	302	19 accordance with the classes of persons designated in Section
303	303	20 5-2.
304	304	21 The Department of Healthcare and Family Services must
305	305	22 provide coverage and reimbursement for amino acid-based
306	306	23 elemental formulas, regardless of delivery method, for the
307	307	24 diagnosis and treatment of (i) eosinophilic disorders and (ii)
308	308	25 short bowel syndrome when the prescribing physician has issued
309	309	26 a written order stating that the amino acid-based elemental
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320	320	1 formula is medically necessary.
321	321	2 The Illinois Department shall authorize the provision of,
322	322	3 and shall authorize payment for, screening by low-dose
323	323	4 mammography for the presence of occult breast cancer for
324	324	5 individuals 35 years of age or older who are eligible for
325	325	6 medical assistance under this Article, as follows:
326	326	7 (A) A baseline mammogram for individuals 35 to 39
327	327	8 years of age.
328	328	9 (B) An annual mammogram for individuals 40 years of
329	329	10 age or older.
330	330	11 (C) A mammogram at the age and intervals considered
331	331	12 medically necessary by the individual's health care
332	332	13 provider for individuals under 40 years of age and having
333	333	14 a family history of breast cancer, prior personal history
334	334	15 of breast cancer, positive genetic testing, or other risk
335	335	16 factors.
336	336	17 (D) A comprehensive ultrasound screening and MRI of an
337	337	18 entire breast or breasts if a mammogram demonstrates
338	338	19 heterogeneous or dense breast tissue or when medically
339	339	20 necessary as determined by a physician licensed to
340	340	21 practice medicine in all of its branches.
341	341	22 (E) A screening MRI when medically necessary, as
342	342	23 determined by a physician licensed to practice medicine in
343	343	24 all of its branches.
344	344	25 (F) A diagnostic mammogram when medically necessary,
345	345	26 as determined by a physician licensed to practice medicine
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356	356	1 in all its branches, advanced practice registered nurse,
357	357	2 or physician assistant.
358	358	3 The Department shall not impose a deductible, coinsurance,
359	359	4 copayment, or any other cost-sharing requirement on the
360	360	5 coverage provided under this paragraph; except that this
361	361	6 sentence does not apply to coverage of diagnostic mammograms
362	362	7 to the extent such coverage would disqualify a high-deductible
363	363	8 health plan from eligibility for a health savings account
364	364	9 pursuant to Section 223 of the Internal Revenue Code (26
365	365	10 U.S.C. 223).
366	366	11 All screenings shall include a physical breast exam,
367	367	12 instruction on self-examination and information regarding the
368	368	13 frequency of self-examination and its value as a preventative
369	369	14 tool.
370	370	15 For purposes of this Section:
371	371	16 "Diagnostic mammogram" means a mammogram obtained using
372	372	17 diagnostic mammography.
373	373	18 "Diagnostic mammography" means a method of screening that
374	374	19 is designed to evaluate an abnormality in a breast, including
375	375	20 an abnormality seen or suspected on a screening mammogram or a
376	376	21 subjective or objective abnormality otherwise detected in the
377	377	22 breast.
378	378	23 "Low-dose mammography" means the x-ray examination of the
379	379	24 breast using equipment dedicated specifically for mammography,
380	380	25 including the x-ray tube, filter, compression device, and
381	381	26 image receptor, with an average radiation exposure delivery of
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392	392	1 less than one rad per breast for 2 views of an average size
393	393	2 breast. The term also includes digital mammography and
394	394	3 includes breast tomosynthesis.
395	395	4 "Breast tomosynthesis" means a radiologic procedure that
396	396	5 involves the acquisition of projection images over the
397	397	6 stationary breast to produce cross-sectional digital
398	398	7 three-dimensional images of the breast.
399	399	8 If, at any time, the Secretary of the United States
400	400	9 Department of Health and Human Services, or its successor
401	401	10 agency, promulgates rules or regulations to be published in
402	402	11 the Federal Register or publishes a comment in the Federal
403	403	12 Register or issues an opinion, guidance, or other action that
404	404	13 would require the State, pursuant to any provision of the
405	405	14 Patient Protection and Affordable Care Act (Public Law
406	406	15 111-148), including, but not limited to, 42 U.S.C.
407	407	16 18031(d)(3)(B) or any successor provision, to defray the cost
408	408	17 of any coverage for breast tomosynthesis outlined in this
409	409	18 paragraph, then the requirement that an insurer cover breast
410	410	19 tomosynthesis is inoperative other than any such coverage
411	411	20 authorized under Section 1902 of the Social Security Act, 42
412	412	21 U.S.C. 1396a, and the State shall not assume any obligation
413	413	22 for the cost of coverage for breast tomosynthesis set forth in
414	414	23 this paragraph.
415	415	24 On and after January 1, 2016, the Department shall ensure
416	416	25 that all networks of care for adult clients of the Department
417	417	26 include access to at least one breast imaging Center of
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428	428	1 Imaging Excellence as certified by the American College of
429	429	2 Radiology.
430	430	3 On and after January 1, 2012, providers participating in a
431	431	4 quality improvement program approved by the Department shall
432	432	5 be reimbursed for screening and diagnostic mammography at the
433	433	6 same rate as the Medicare program's rates, including the
434	434	7 increased reimbursement for digital mammography and, after
435	435	8 January 1, 2023 (the effective date of Public Act 102-1018),
436	436	9 breast tomosynthesis.
437	437	10 The Department shall convene an expert panel including
438	438	11 representatives of hospitals, free-standing mammography
439	439	12 facilities, and doctors, including radiologists, to establish
440	440	13 quality standards for mammography.
441	441	14 On and after January 1, 2017, providers participating in a
442	442	15 breast cancer treatment quality improvement program approved
443	443	16 by the Department shall be reimbursed for breast cancer
444	444	17 treatment at a rate that is no lower than 95% of the Medicare
445	445	18 program's rates for the data elements included in the breast
446	446	19 cancer treatment quality program.
447	447	20 The Department shall convene an expert panel, including
448	448	21 representatives of hospitals, free-standing breast cancer
449	449	22 treatment centers, breast cancer quality organizations, and
450	450	23 doctors, including breast surgeons, reconstructive breast
451	451	24 surgeons, oncologists, and primary care providers to establish
452	452	25 quality standards for breast cancer treatment.
453	453	26 Subject to federal approval, the Department shall
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464	464	1 establish a rate methodology for mammography at federally
465	465	2 qualified health centers and other encounter-rate clinics.
466	466	3 These clinics or centers may also collaborate with other
467	467	4 hospital-based mammography facilities. By January 1, 2016, the
468	468	5 Department shall report to the General Assembly on the status
469	469	6 of the provision set forth in this paragraph.
470	470	7 The Department shall establish a methodology to remind
471	471	8 individuals who are age-appropriate for screening mammography,
472	472	9 but who have not received a mammogram within the previous 18
473	473	10 months, of the importance and benefit of screening
474	474	11 mammography. The Department shall work with experts in breast
475	475	12 cancer outreach and patient navigation to optimize these
476	476	13 reminders and shall establish a methodology for evaluating
477	477	14 their effectiveness and modifying the methodology based on the
478	478	15 evaluation.
479	479	16 The Department shall establish a performance goal for
480	480	17 primary care providers with respect to their female patients
481	481	18 over age 40 receiving an annual mammogram. This performance
482	482	19 goal shall be used to provide additional reimbursement in the
483	483	20 form of a quality performance bonus to primary care providers
484	484	21 who meet that goal.
485	485	22 The Department shall devise a means of case-managing or
486	486	23 patient navigation for beneficiaries diagnosed with breast
487	487	24 cancer. This program shall initially operate as a pilot
488	488	25 program in areas of the State with the highest incidence of
489	489	26 mortality related to breast cancer. At least one pilot program
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500	500	1 site shall be in the metropolitan Chicago area and at least one
501	501	2 site shall be outside the metropolitan Chicago area. On or
502	502	3 after July 1, 2016, the pilot program shall be expanded to
503	503	4 include one site in western Illinois, one site in southern
504	504	5 Illinois, one site in central Illinois, and 4 sites within
505	505	6 metropolitan Chicago. An evaluation of the pilot program shall
506	506	7 be carried out measuring health outcomes and cost of care for
507	507	8 those served by the pilot program compared to similarly
508	508	9 situated patients who are not served by the pilot program.
509	509	10 The Department shall require all networks of care to
510	510	11 develop a means either internally or by contract with experts
511	511	12 in navigation and community outreach to navigate cancer
512	512	13 patients to comprehensive care in a timely fashion. The
513	513	14 Department shall require all networks of care to include
514	514	15 access for patients diagnosed with cancer to at least one
515	515	16 academic commission on cancer-accredited cancer program as an
516	516	17 in-network covered benefit.
517	517	18 The Department shall provide coverage and reimbursement
518	518	19 for a human papillomavirus (HPV) vaccine that is approved for
519	519	20 marketing by the federal Food and Drug Administration for all
520	520	21 persons between the ages of 9 and 45. Subject to federal
521	521	22 approval, the Department shall provide coverage and
522	522	23 reimbursement for a human papillomavirus (HPV) vaccine for
523	523	24 persons of the age of 46 and above who have been diagnosed with
524	524	25 cervical dysplasia with a high risk of recurrence or
525	525	26 progression. The Department shall disallow any
526	526
527	527
528	528
529	529
530	530
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533	533
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536	536	1 preauthorization requirements for the administration of the
537	537	2 human papillomavirus (HPV) vaccine.
538	538	3 On or after July 1, 2022, individuals who are otherwise
539	539	4 eligible for medical assistance under this Article shall
540	540	5 receive coverage for perinatal depression screenings for the
541	541	6 12-month period beginning on the last day of their pregnancy.
542	542	7 Medical assistance coverage under this paragraph shall be
543	543	8 conditioned on the use of a screening instrument approved by
544	544	9 the Department.
545	545	10 Any medical or health care provider shall immediately
546	546	11 recommend, to any pregnant individual who is being provided
547	547	12 prenatal services and is suspected of having a substance use
548	548	13 disorder as defined in the Substance Use Disorder Act,
549	549	14 referral to a local substance use disorder treatment program
550	550	15 licensed by the Department of Human Services or to a licensed
551	551	16 hospital which provides substance abuse treatment services.
552	552	17 The Department of Healthcare and Family Services shall assure
553	553	18 coverage for the cost of treatment of the drug abuse or
554	554	19 addiction for pregnant recipients in accordance with the
555	555	20 Illinois Medicaid Program in conjunction with the Department
556	556	21 of Human Services.
557	557	22 All medical providers providing medical assistance to
558	558	23 pregnant individuals under this Code shall receive information
559	559	24 from the Department on the availability of services under any
560	560	25 program providing case management services for addicted
561	561	26 individuals, including information on appropriate referrals
562	562
563	563
564	564
565	565
566	566
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568	568
569	569
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572	572	1 for other social services that may be needed by addicted
573	573	2 individuals in addition to treatment for addiction.
574	574	3 The Illinois Department, in cooperation with the
575	575	4 Departments of Human Services (as successor to the Department
576	576	5 of Alcoholism and Substance Abuse) and Public Health, through
577	577	6 a public awareness campaign, may provide information
578	578	7 concerning treatment for alcoholism and drug abuse and
579	579	8 addiction, prenatal health care, and other pertinent programs
580	580	9 directed at reducing the number of drug-affected infants born
581	581	10 to recipients of medical assistance.
582	582	11 Neither the Department of Healthcare and Family Services
583	583	12 nor the Department of Human Services shall sanction the
584	584	13 recipient solely on the basis of the recipient's substance
585	585	14 abuse.
586	586	15 The Illinois Department shall establish such regulations
587	587	16 governing the dispensing of health services under this Article
588	588	17 as it shall deem appropriate. The Department should seek the
589	589	18 advice of formal professional advisory committees appointed by
590	590	19 the Director of the Illinois Department for the purpose of
591	591	20 providing regular advice on policy and administrative matters,
592	592	21 information dissemination and educational activities for
593	593	22 medical and health care providers, and consistency in
594	594	23 procedures to the Illinois Department.
595	595	24 The Illinois Department may develop and contract with
596	596	25 Partnerships of medical providers to arrange medical services
597	597	26 for persons eligible under Section 5-2 of this Code.
598	598
599	599
600	600
601	601
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608	608	1 Implementation of this Section may be by demonstration
609	609	2 projects in certain geographic areas. The Partnership shall be
610	610	3 represented by a sponsor organization. The Department, by
611	611	4 rule, shall develop qualifications for sponsors of
612	612	5 Partnerships. Nothing in this Section shall be construed to
613	613	6 require that the sponsor organization be a medical
614	614	7 organization.
615	615	8 The sponsor must negotiate formal written contracts with
616	616	9 medical providers for physician services, inpatient and
617	617	10 outpatient hospital care, home health services, treatment for
618	618	11 alcoholism and substance abuse, and other services determined
619	619	12 necessary by the Illinois Department by rule for delivery by
620	620	13 Partnerships. Physician services must include prenatal and
621	621	14 obstetrical care. The Illinois Department shall reimburse
622	622	15 medical services delivered by Partnership providers to clients
623	623	16 in target areas according to provisions of this Article and
624	624	17 the Illinois Health Finance Reform Act, except that:
625	625	18 (1) Physicians participating in a Partnership and
626	626	19 providing certain services, which shall be determined by
627	627	20 the Illinois Department, to persons in areas covered by
628	628	21 the Partnership may receive an additional surcharge for
629	629	22 such services.
630	630	23 (2) The Department may elect to consider and negotiate
631	631	24 financial incentives to encourage the development of
632	632	25 Partnerships and the efficient delivery of medical care.
633	633	26 (3) Persons receiving medical services through
634	634
635	635
636	636
637	637
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640	640
641	641
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644	644	1 Partnerships may receive medical and case management
645	645	2 services above the level usually offered through the
646	646	3 medical assistance program.
647	647	4 Medical providers shall be required to meet certain
648	648	5 qualifications to participate in Partnerships to ensure the
649	649	6 delivery of high quality medical services. These
650	650	7 qualifications shall be determined by rule of the Illinois
651	651	8 Department and may be higher than qualifications for
652	652	9 participation in the medical assistance program. Partnership
653	653	10 sponsors may prescribe reasonable additional qualifications
654	654	11 for participation by medical providers, only with the prior
655	655	12 written approval of the Illinois Department.
656	656	13 Nothing in this Section shall limit the free choice of
657	657	14 practitioners, hospitals, and other providers of medical
658	658	15 services by clients. In order to ensure patient freedom of
659	659	16 choice, the Illinois Department shall immediately promulgate
660	660	17 all rules and take all other necessary actions so that
661	661	18 provided services may be accessed from therapeutically
662	662	19 certified optometrists to the full extent of the Illinois
663	663	20 Optometric Practice Act of 1987 without discriminating between
664	664	21 service providers.
665	665	22 The Department shall apply for a waiver from the United
666	666	23 States Health Care Financing Administration to allow for the
667	667	24 implementation of Partnerships under this Section.
668	668	25 The Illinois Department shall require health care
669	669	26 providers to maintain records that document the medical care
670	670
671	671
672	672
673	673
674	674
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680	680	1 and services provided to recipients of Medical Assistance
681	681	2 under this Article. Such records must be retained for a period
682	682	3 of not less than 6 years from the date of service or as
683	683	4 provided by applicable State law, whichever period is longer,
684	684	5 except that if an audit is initiated within the required
685	685	6 retention period then the records must be retained until the
686	686	7 audit is completed and every exception is resolved. The
687	687	8 Illinois Department shall require health care providers to
688	688	9 make available, when authorized by the patient, in writing,
689	689	10 the medical records in a timely fashion to other health care
690	690	11 providers who are treating or serving persons eligible for
691	691	12 Medical Assistance under this Article. All dispensers of
692	692	13 medical services shall be required to maintain and retain
693	693	14 business and professional records sufficient to fully and
694	694	15 accurately document the nature, scope, details and receipt of
695	695	16 the health care provided to persons eligible for medical
696	696	17 assistance under this Code, in accordance with regulations
697	697	18 promulgated by the Illinois Department. The rules and
698	698	19 regulations shall require that proof of the receipt of
699	699	20 prescription drugs, dentures, prosthetic devices and
700	700	21 eyeglasses by eligible persons under this Section accompany
701	701	22 each claim for reimbursement submitted by the dispenser of
702	702	23 such medical services. No such claims for reimbursement shall
703	703	24 be approved for payment by the Illinois Department without
704	704	25 such proof of receipt, unless the Illinois Department shall
705	705	26 have put into effect and shall be operating a system of
706	706
707	707
708	708
709	709
710	710
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712	712
713	713
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716	716	1 post-payment audit and review which shall, on a sampling
717	717	2 basis, be deemed adequate by the Illinois Department to assure
718	718	3 that such drugs, dentures, prosthetic devices and eyeglasses
719	719	4 for which payment is being made are actually being received by
720	720	5 eligible recipients. Within 90 days after September 16, 1984
721	721	6 (the effective date of Public Act 83-1439), the Illinois
722	722	7 Department shall establish a current list of acquisition costs
723	723	8 for all prosthetic devices and any other items recognized as
724	724	9 medical equipment and supplies reimbursable under this Article
725	725	10 and shall update such list on a quarterly basis, except that
726	726	11 the acquisition costs of all prescription drugs shall be
727	727	12 updated no less frequently than every 30 days as required by
728	728	13 Section 5-5.12.
729	729	14 Notwithstanding any other law to the contrary, the
730	730	15 Illinois Department shall, within 365 days after July 22, 2013
731	731	16 (the effective date of Public Act 98-104), establish
732	732	17 procedures to permit skilled care facilities licensed under
733	733	18 the Nursing Home Care Act to submit monthly billing claims for
734	734	19 reimbursement purposes. Following development of these
735	735	20 procedures, the Department shall, by July 1, 2016, test the
736	736	21 viability of the new system and implement any necessary
737	737	22 operational or structural changes to its information
738	738	23 technology platforms in order to allow for the direct
739	739	24 acceptance and payment of nursing home claims.
740	740	25 Notwithstanding any other law to the contrary, the
741	741	26 Illinois Department shall, within 365 days after August 15,
742	742
743	743
744	744
745	745
746	746
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748	748
749	749
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752	752	1 2014 (the effective date of Public Act 98-963), establish
753	753	2 procedures to permit ID/DD facilities licensed under the ID/DD
754	754	3 Community Care Act and MC/DD facilities licensed under the
755	755	4 MC/DD Act to submit monthly billing claims for reimbursement
756	756	5 purposes. Following development of these procedures, the
757	757	6 Department shall have an additional 365 days to test the
758	758	7 viability of the new system and to ensure that any necessary
759	759	8 operational or structural changes to its information
760	760	9 technology platforms are implemented.
761	761	10 The Illinois Department shall require all dispensers of
762	762	11 medical services, other than an individual practitioner or
763	763	12 group of practitioners, desiring to participate in the Medical
764	764	13 Assistance program established under this Article to disclose
765	765	14 all financial, beneficial, ownership, equity, surety or other
766	766	15 interests in any and all firms, corporations, partnerships,
767	767	16 associations, business enterprises, joint ventures, agencies,
768	768	17 institutions or other legal entities providing any form of
769	769	18 health care services in this State under this Article.
770	770	19 The Illinois Department may require that all dispensers of
771	771	20 medical services desiring to participate in the medical
772	772	21 assistance program established under this Article disclose,
773	773	22 under such terms and conditions as the Illinois Department may
774	774	23 by rule establish, all inquiries from clients and attorneys
775	775	24 regarding medical bills paid by the Illinois Department, which
776	776	25 inquiries could indicate potential existence of claims or
777	777	26 liens for the Illinois Department.
778	778
779	779
780	780
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784	784
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788	788	1 Enrollment of a vendor shall be subject to a provisional
789	789	2 period and shall be conditional for one year. During the
790	790	3 period of conditional enrollment, the Department may terminate
791	791	4 the vendor's eligibility to participate in, or may disenroll
792	792	5 the vendor from, the medical assistance program without cause.
793	793	6 Unless otherwise specified, such termination of eligibility or
794	794	7 disenrollment is not subject to the Department's hearing
795	795	8 process. However, a disenrolled vendor may reapply without
796	796	9 penalty.
797	797	10 The Department has the discretion to limit the conditional
798	798	11 enrollment period for vendors based upon the category of risk
799	799	12 of the vendor.
800	800	13 Prior to enrollment and during the conditional enrollment
801	801	14 period in the medical assistance program, all vendors shall be
802	802	15 subject to enhanced oversight, screening, and review based on
803	803	16 the risk of fraud, waste, and abuse that is posed by the
804	804	17 category of risk of the vendor. The Illinois Department shall
805	805	18 establish the procedures for oversight, screening, and review,
806	806	19 which may include, but need not be limited to: criminal and
807	807	20 financial background checks; fingerprinting; license,
808	808	21 certification, and authorization verifications; unscheduled or
809	809	22 unannounced site visits; database checks; prepayment audit
810	810	23 reviews; audits; payment caps; payment suspensions; and other
811	811	24 screening as required by federal or State law.
812	812	25 The Department shall define or specify the following: (i)
813	813	26 by provider notice, the "category of risk of the vendor" for
814	814
815	815
816	816
817	817
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820	820
821	821
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824	824	1 each type of vendor, which shall take into account the level of
825	825	2 screening applicable to a particular category of vendor under
826	826	3 federal law and regulations; (ii) by rule or provider notice,
827	827	4 the maximum length of the conditional enrollment period for
828	828	5 each category of risk of the vendor; and (iii) by rule, the
829	829	6 hearing rights, if any, afforded to a vendor in each category
830	830	7 of risk of the vendor that is terminated or disenrolled during
831	831	8 the conditional enrollment period.
832	832	9 To be eligible for payment consideration, a vendor's
833	833	10 payment claim or bill, either as an initial claim or as a
834	834	11 resubmitted claim following prior rejection, must be received
835	835	12 by the Illinois Department, or its fiscal intermediary, no
836	836	13 later than 180 days after the latest date on the claim on which
837	837	14 medical goods or services were provided, with the following
838	838	15 exceptions:
839	839	16 (1) In the case of a provider whose enrollment is in
840	840	17 process by the Illinois Department, the 180-day period
841	841	18 shall not begin until the date on the written notice from
842	842	19 the Illinois Department that the provider enrollment is
843	843	20 complete.
844	844	21 (2) In the case of errors attributable to the Illinois
845	845	22 Department or any of its claims processing intermediaries
846	846	23 which result in an inability to receive, process, or
847	847	24 adjudicate a claim, the 180-day period shall not begin
848	848	25 until the provider has been notified of the error.
849	849	26 (3) In the case of a provider for whom the Illinois
850	850
851	851
852	852
853	853
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856	856
857	857
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859	859	HB1504 - 24 - LRB104 08529 KTG 18581 b
860	860	1 Department initiates the monthly billing process.
861	861	2 (4) In the case of a provider operated by a unit of
862	862	3 local government with a population exceeding 3,000,000
863	863	4 when local government funds finance federal participation
864	864	5 for claims payments.
865	865	6 For claims for services rendered during a period for which
866	866	7 a recipient received retroactive eligibility, claims must be
867	867	8 filed within 180 days after the Department determines the
868	868	9 applicant is eligible. For claims for which the Illinois
869	869	10 Department is not the primary payer, claims must be submitted
870	870	11 to the Illinois Department within 180 days after the final
871	871	12 adjudication by the primary payer.
872	872	13 In the case of long term care facilities, within 120
873	873	14 calendar days of receipt by the facility of required
874	874	15 prescreening information, new admissions with associated
875	875	16 admission documents shall be submitted through the Medical
876	876	17 Electronic Data Interchange (MEDI) or the Recipient
877	877	18 Eligibility Verification (REV) System or shall be submitted
878	878	19 directly to the Department of Human Services using required
879	879	20 admission forms. Effective September 1, 2014, admission
880	880	21 documents, including all prescreening information, must be
881	881	22 submitted through MEDI or REV. Confirmation numbers assigned
882	882	23 to an accepted transaction shall be retained by a facility to
883	883	24 verify timely submittal. Once an admission transaction has
884	884	25 been completed, all resubmitted claims following prior
885	885	26 rejection are subject to receipt no later than 180 days after
886	886
887	887
888	888
889	889
890	890
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892	892
893	893
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896	896	1 the admission transaction has been completed.
897	897	2 Claims that are not submitted and received in compliance
898	898	3 with the foregoing requirements shall not be eligible for
899	899	4 payment under the medical assistance program, and the State
900	900	5 shall have no liability for payment of those claims.
901	901	6 To the extent consistent with applicable information and
902	902	7 privacy, security, and disclosure laws, State and federal
903	903	8 agencies and departments shall provide the Illinois Department
904	904	9 access to confidential and other information and data
905	905	10 necessary to perform eligibility and payment verifications and
906	906	11 other Illinois Department functions. This includes, but is not
907	907	12 limited to: information pertaining to licensure;
908	908	13 certification; earnings; immigration status; citizenship; wage
909	909	14 reporting; unearned and earned income; pension income;
910	910	15 employment; supplemental security income; social security
911	911	16 numbers; National Provider Identifier (NPI) numbers; the
912	912	17 National Practitioner Data Bank (NPDB); program and agency
913	913	18 exclusions; taxpayer identification numbers; tax delinquency;
914	914	19 corporate information; and death records.
915	915	20 The Illinois Department shall enter into agreements with
916	916	21 State agencies and departments, and is authorized to enter
917	917	22 into agreements with federal agencies and departments, under
918	918	23 which such agencies and departments shall share data necessary
919	919	24 for medical assistance program integrity functions and
920	920	25 oversight. The Illinois Department shall develop, in
921	921	26 cooperation with other State departments and agencies, and in
922	922
923	923
924	924
925	925
926	926
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928	928
929	929
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931	931	HB1504 - 26 - LRB104 08529 KTG 18581 b
932	932	1 compliance with applicable federal laws and regulations,
933	933	2 appropriate and effective methods to share such data. At a
934	934	3 minimum, and to the extent necessary to provide data sharing,
935	935	4 the Illinois Department shall enter into agreements with State
936	936	5 agencies and departments, and is authorized to enter into
937	937	6 agreements with federal agencies and departments, including,
938	938	7 but not limited to: the Secretary of State; the Department of
939	939	8 Revenue; the Department of Public Health; the Department of
940	940	9 Human Services; and the Department of Financial and
941	941	10 Professional Regulation.
942	942	11 Beginning in fiscal year 2013, the Illinois Department
943	943	12 shall set forth a request for information to identify the
944	944	13 benefits of a pre-payment, post-adjudication, and post-edit
945	945	14 claims system with the goals of streamlining claims processing
946	946	15 and provider reimbursement, reducing the number of pending or
947	947	16 rejected claims, and helping to ensure a more transparent
948	948	17 adjudication process through the utilization of: (i) provider
949	949	18 data verification and provider screening technology; and (ii)
950	950	19 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
951	951	20 post-adjudicated predictive modeling with an integrated case
952	952	21 management system with link analysis. Such a request for
953	953	22 information shall not be considered as a request for proposal
954	954	23 or as an obligation on the part of the Illinois Department to
955	955	24 take any action or acquire any products or services.
956	956	25 The Illinois Department shall establish policies,
957	957	26 procedures, standards and criteria by rule for the
958	958
959	959
960	960
961	961
962	962
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964	964
965	965
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968	968	1 acquisition, repair and replacement of orthotic and prosthetic
969	969	2 devices and durable medical equipment. Such rules shall
970	970	3 provide, but not be limited to, the following services: (1)
971	971	4 immediate repair or replacement of such devices by recipients;
972	972	5 and (2) rental, lease, purchase or lease-purchase of durable
973	973	6 medical equipment in a cost-effective manner, taking into
974	974	7 consideration the recipient's medical prognosis, the extent of
975	975	8 the recipient's needs, and the requirements and costs for
976	976	9 maintaining such equipment. Subject to prior approval, such
977	977	10 rules shall enable a recipient to temporarily acquire and use
978	978	11 alternative or substitute devices or equipment pending repairs
979	979	12 or replacements of any device or equipment previously
980	980	13 authorized for such recipient by the Department.
981	981	14 Notwithstanding any provision of Section 5-5f to the contrary,
982	982	15 the Department may, by rule, exempt certain replacement
983	983	16 wheelchair parts from prior approval and, for wheelchairs,
984	984	17 wheelchair parts, wheelchair accessories, and related seating
985	985	18 and positioning items, determine the wholesale price by
986	986	19 methods other than actual acquisition costs.
987	987	20 The Department shall require, by rule, all providers of
988	988	21 durable medical equipment to be accredited by an accreditation
989	989	22 organization approved by the federal Centers for Medicare and
990	990	23 Medicaid Services and recognized by the Department in order to
991	991	24 bill the Department for providing durable medical equipment to
992	992	25 recipients. No later than 15 months after the effective date
993	993	26 of the rule adopted pursuant to this paragraph, all providers
994	994
995	995
996	996
997	997
998	998
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1000	1000
1001	1001
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1004	1004	1 must meet the accreditation requirement.
1005	1005	2 In order to promote environmental responsibility, meet the
1006	1006	3 needs of recipients and enrollees, and achieve significant
1007	1007	4 cost savings, the Department, or a managed care organization
1008	1008	5 under contract with the Department, may provide recipients or
1009	1009	6 managed care enrollees who have a prescription or Certificate
1010	1010	7 of Medical Necessity access to refurbished durable medical
1011	1011	8 equipment under this Section (excluding prosthetic and
1012	1012	9 orthotic devices as defined in the Orthotics, Prosthetics, and
1013	1013	10 Pedorthics Practice Act and complex rehabilitation technology
1014	1014	11 products and associated services) through the State's
1015	1015	12 assistive technology program's reutilization program, using
1016	1016	13 staff with the Assistive Technology Professional (ATP)
1017	1017	14 Certification if the refurbished durable medical equipment:
1018	1018	15 (i) is available; (ii) is less expensive, including shipping
1019	1019	16 costs, than new durable medical equipment of the same type;
1020	1020	17 (iii) is able to withstand at least 3 years of use; (iv) is
1021	1021	18 cleaned, disinfected, sterilized, and safe in accordance with
1022	1022	19 federal Food and Drug Administration regulations and guidance
1023	1023	20 governing the reprocessing of medical devices in health care
1024	1024	21 settings; and (v) equally meets the needs of the recipient or
1025	1025	22 enrollee. The reutilization program shall confirm that the
1026	1026	23 recipient or enrollee is not already in receipt of the same or
1027	1027	24 similar equipment from another service provider, and that the
1028	1028	25 refurbished durable medical equipment equally meets the needs
1029	1029	26 of the recipient or enrollee. Nothing in this paragraph shall
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB1504 - 28 - LRB104 08529 KTG 18581 b
1036	1036
1037	1037
1038	1038	HB1504- 29 -LRB104 08529 KTG 18581 b HB1504 - 29 - LRB104 08529 KTG 18581 b
1039	1039	HB1504 - 29 - LRB104 08529 KTG 18581 b
1040	1040	1 be construed to limit recipient or enrollee choice to obtain
1041	1041	2 new durable medical equipment or place any additional prior
1042	1042	3 authorization conditions on enrollees of managed care
1043	1043	4 organizations.
1044	1044	5 The Department shall execute, relative to the nursing home
1045	1045	6 prescreening project, written inter-agency agreements with the
1046	1046	7 Department of Human Services and the Department on Aging, to
1047	1047	8 effect the following: (i) intake procedures and common
1048	1048	9 eligibility criteria for those persons who are receiving
1049	1049	10 non-institutional services; and (ii) the establishment and
1050	1050	11 development of non-institutional services in areas of the
1051	1051	12 State where they are not currently available or are
1052	1052	13 undeveloped; and (iii) notwithstanding any other provision of
1053	1053	14 law, subject to federal approval, on and after July 1, 2012, an
1054	1054	15 increase in the determination of need (DON) scores from 29 to
1055	1055	16 37 for applicants for institutional and home and
1056	1056	17 community-based long term care; if and only if federal
1057	1057	18 approval is not granted, the Department may, in conjunction
1058	1058	19 with other affected agencies, implement utilization controls
1059	1059	20 or changes in benefit packages to effectuate a similar savings
1060	1060	21 amount for this population; and (iv) no later than July 1,
1061	1061	22 2013, minimum level of care eligibility criteria for
1062	1062	23 institutional and home and community-based long term care; and
1063	1063	24 (v) no later than October 1, 2013, establish procedures to
1064	1064	25 permit long term care providers access to eligibility scores
1065	1065	26 for individuals with an admission date who are seeking or
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB1504 - 29 - LRB104 08529 KTG 18581 b
1072	1072
1073	1073
1074	1074	HB1504- 30 -LRB104 08529 KTG 18581 b HB1504 - 30 - LRB104 08529 KTG 18581 b
1075	1075	HB1504 - 30 - LRB104 08529 KTG 18581 b
1076	1076	1 receiving services from the long term care provider. In order
1077	1077	2 to select the minimum level of care eligibility criteria, the
1078	1078	3 Governor shall establish a workgroup that includes affected
1079	1079	4 agency representatives and stakeholders representing the
1080	1080	5 institutional and home and community-based long term care
1081	1081	6 interests. This Section shall not restrict the Department from
1082	1082	7 implementing lower level of care eligibility criteria for
1083	1083	8 community-based services in circumstances where federal
1084	1084	9 approval has been granted.
1085	1085	10 The Illinois Department shall develop and operate, in
1086	1086	11 cooperation with other State Departments and agencies and in
1087	1087	12 compliance with applicable federal laws and regulations,
1088	1088	13 appropriate and effective systems of health care evaluation
1089	1089	14 and programs for monitoring of utilization of health care
1090	1090	15 services and facilities, as it affects persons eligible for
1091	1091	16 medical assistance under this Code.
1092	1092	17 The Illinois Department shall report annually to the
1093	1093	18 General Assembly, no later than the second Friday in April of
1094	1094	19 1979 and each year thereafter, in regard to:
1095	1095	20 (a) actual statistics and trends in utilization of
1096	1096	21 medical services by public aid recipients;
1097	1097	22 (b) actual statistics and trends in the provision of
1098	1098	23 the various medical services by medical vendors;
1099	1099	24 (c) current rate structures and proposed changes in
1100	1100	25 those rate structures for the various medical vendors; and
1101	1101	26 (d) efforts at utilization review and control by the
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB1504 - 30 - LRB104 08529 KTG 18581 b
1108	1108
1109	1109
1110	1110	HB1504- 31 -LRB104 08529 KTG 18581 b HB1504 - 31 - LRB104 08529 KTG 18581 b
1111	1111	HB1504 - 31 - LRB104 08529 KTG 18581 b
1112	1112	1 Illinois Department.
1113	1113	2 The period covered by each report shall be the 3 years
1114	1114	3 ending on the June 30 prior to the report. The report shall
1115	1115	4 include suggested legislation for consideration by the General
1116	1116	5 Assembly. The requirement for reporting to the General
1117	1117	6 Assembly shall be satisfied by filing copies of the report as
1118	1118	7 required by Section 3.1 of the General Assembly Organization
1119	1119	8 Act, and filing such additional copies with the State
1120	1120	9 Government Report Distribution Center for the General Assembly
1121	1121	10 as is required under paragraph (t) of Section 7 of the State
1122	1122	11 Library Act.
1123	1123	12 Rulemaking authority to implement Public Act 95-1045, if
1124	1124	13 any, is conditioned on the rules being adopted in accordance
1125	1125	14 with all provisions of the Illinois Administrative Procedure
1126	1126	15 Act and all rules and procedures of the Joint Committee on
1127	1127	16 Administrative Rules; any purported rule not so adopted, for
1128	1128	17 whatever reason, is unauthorized.
1129	1129	18 On and after July 1, 2012, the Department shall reduce any
1130	1130	19 rate of reimbursement for services or other payments or alter
1131	1131	20 any methodologies authorized by this Code to reduce any rate
1132	1132	21 of reimbursement for services or other payments in accordance
1133	1133	22 with Section 5-5e.
1134	1134	23 Because kidney transplantation can be an appropriate,
1135	1135	24 cost-effective alternative to renal dialysis when medically
1136	1136	25 necessary and notwithstanding the provisions of Section 1-11
1137	1137	26 of this Code, beginning October 1, 2014, the Department shall
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB1504 - 31 - LRB104 08529 KTG 18581 b
1144	1144
1145	1145
1146	1146	HB1504- 32 -LRB104 08529 KTG 18581 b HB1504 - 32 - LRB104 08529 KTG 18581 b
1147	1147	HB1504 - 32 - LRB104 08529 KTG 18581 b
1148	1148	1 cover kidney transplantation for noncitizens with end-stage
1149	1149	2 renal disease who are not eligible for comprehensive medical
1150	1150	3 benefits, who meet the residency requirements of Section 5-3
1151	1151	4 of this Code, and who would otherwise meet the financial
1152	1152	5 requirements of the appropriate class of eligible persons
1153	1153	6 under Section 5-2 of this Code. To qualify for coverage of
1154	1154	7 kidney transplantation, such person must be receiving
1155	1155	8 emergency renal dialysis services covered by the Department.
1156	1156	9 Providers under this Section shall be prior approved and
1157	1157	10 certified by the Department to perform kidney transplantation
1158	1158	11 and the services under this Section shall be limited to
1159	1159	12 services associated with kidney transplantation.
1160	1160	13 Notwithstanding any other provision of this Code to the
1161	1161	14 contrary, on or after July 1, 2015, all FDA-approved FDA
1162	1162	15 approved forms of medication assisted treatment prescribed for
1163	1163	16 the treatment of alcohol dependence or treatment of opioid
1164	1164	17 dependence shall be covered under both fee-for-service and
1165	1165	18 managed care medical assistance programs for persons who are
1166	1166	19 otherwise eligible for medical assistance under this Article
1167	1167	20 and shall not be subject to any (1) utilization control, other
1168	1168	21 than those established under the American Society of Addiction
1169	1169	22 Medicine patient placement criteria, (2) prior authorization
1170	1170	23 mandate, (3) lifetime restriction limit mandate, or (4)
1171	1171	24 limitations on dosage.
1172	1172	25 On or after July 1, 2015, opioid antagonists prescribed
1173	1173	26 for the treatment of an opioid overdose, including the
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB1504 - 32 - LRB104 08529 KTG 18581 b
1180	1180
1181	1181
1182	1182	HB1504- 33 -LRB104 08529 KTG 18581 b HB1504 - 33 - LRB104 08529 KTG 18581 b
1183	1183	HB1504 - 33 - LRB104 08529 KTG 18581 b
1184	1184	1 medication product, administration devices, and any pharmacy
1185	1185	2 fees or hospital fees related to the dispensing, distribution,
1186	1186	3 and administration of the opioid antagonist, shall be covered
1187	1187	4 under the medical assistance program for persons who are
1188	1188	5 otherwise eligible for medical assistance under this Article.
1189	1189	6 As used in this Section, "opioid antagonist" means a drug that
1190	1190	7 binds to opioid receptors and blocks or inhibits the effect of
1191	1191	8 opioids acting on those receptors, including, but not limited
1192	1192	9 to, naloxone hydrochloride or any other similarly acting drug
1193	1193	10 approved by the U.S. Food and Drug Administration. The
1194	1194	11 Department shall not impose a copayment on the coverage
1195	1195	12 provided for naloxone hydrochloride under the medical
1196	1196	13 assistance program.
1197	1197	14 Upon federal approval, the Department shall provide
1198	1198	15 coverage and reimbursement for all drugs that are approved for
1199	1199	16 marketing by the federal Food and Drug Administration and that
1200	1200	17 are recommended by the federal Public Health Service or the
1201	1201	18 United States Centers for Disease Control and Prevention for
1202	1202	19 pre-exposure prophylaxis and related pre-exposure prophylaxis
1203	1203	20 services, including, but not limited to, HIV and sexually
1204	1204	21 transmitted infection screening, treatment for sexually
1205	1205	22 transmitted infections, medical monitoring, assorted labs, and
1206	1206	23 counseling to reduce the likelihood of HIV infection among
1207	1207	24 individuals who are not infected with HIV but who are at high
1208	1208	25 risk of HIV infection.
1209	1209	26 A federally qualified health center, as defined in Section
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB1504 - 33 - LRB104 08529 KTG 18581 b
1216	1216
1217	1217
1218	1218	HB1504- 34 -LRB104 08529 KTG 18581 b HB1504 - 34 - LRB104 08529 KTG 18581 b
1219	1219	HB1504 - 34 - LRB104 08529 KTG 18581 b
1220	1220	1 1905(l)(2)(B) of the federal Social Security Act, shall be
1221	1221	2 reimbursed by the Department in accordance with the federally
1222	1222	3 qualified health center's encounter rate for services provided
1223	1223	4 to medical assistance recipients that are performed by a
1224	1224	5 dental hygienist, as defined under the Illinois Dental
1225	1225	6 Practice Act, working under the general supervision of a
1226	1226	7 dentist and employed by a federally qualified health center.
1227	1227	8 Within 90 days after October 8, 2021 (the effective date
1228	1228	9 of Public Act 102-665), the Department shall seek federal
1229	1229	10 approval of a State Plan amendment to expand coverage for
1230	1230	11 family planning services that includes presumptive eligibility
1231	1231	12 to individuals whose income is at or below 208% of the federal
1232	1232	13 poverty level. Coverage under this Section shall be effective
1233	1233	14 beginning no later than December 1, 2022.
1234	1234	15 Subject to approval by the federal Centers for Medicare
1235	1235	16 and Medicaid Services of a Title XIX State Plan amendment
1236	1236	17 electing the Program of All-Inclusive Care for the Elderly
1237	1237	18 (PACE) as a State Medicaid option, as provided for by Subtitle
1238	1238	19 I (commencing with Section 4801) of Title IV of the Balanced
1239	1239	20 Budget Act of 1997 (Public Law 105-33) and Part 460
1240	1240	21 (commencing with Section 460.2) of Subchapter E of Title 42 of
1241	1241	22 the Code of Federal Regulations, PACE program services shall
1242	1242	23 become a covered benefit of the medical assistance program,
1243	1243	24 subject to criteria established in accordance with all
1244	1244	25 applicable laws.
1245	1245	26 Notwithstanding any other provision of this Code,
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
1251	1251	HB1504 - 34 - LRB104 08529 KTG 18581 b
1252	1252
1253	1253
1254	1254	HB1504- 35 -LRB104 08529 KTG 18581 b HB1504 - 35 - LRB104 08529 KTG 18581 b
1255	1255	HB1504 - 35 - LRB104 08529 KTG 18581 b
1256	1256	1 community-based pediatric palliative care from a trained
1257	1257	2 interdisciplinary team shall be covered under the medical
1258	1258	3 assistance program as provided in Section 15 of the Pediatric
1259	1259	4 Palliative Care Act.
1260	1260	5 Notwithstanding any other provision of this Code, within
1261	1261	6 12 months after June 2, 2022 (the effective date of Public Act
1262	1262	7 102-1037) and subject to federal approval, acupuncture
1263	1263	8 services performed by an acupuncturist licensed under the
1264	1264	9 Acupuncture Practice Act who is acting within the scope of his
1265	1265	10 or her license shall be covered under the medical assistance
1266	1266	11 program. The Department shall apply for any federal waiver or
1267	1267	12 State Plan amendment, if required, to implement this
1268	1268	13 paragraph. The Department may adopt any rules, including
1269	1269	14 standards and criteria, necessary to implement this paragraph.
1270	1270	15 Notwithstanding any other provision of this Code, the
1271	1271	16 medical assistance program shall, subject to federal approval,
1272	1272	17 reimburse hospitals for costs associated with a newborn
1273	1273	18 screening test for the presence of metachromatic
1274	1274	19 leukodystrophy, as required under the Newborn Metabolic
1275	1275	20 Screening Act, at a rate not less than the fee charged by the
1276	1276	21 Department of Public Health. Notwithstanding any other
1277	1277	22 provision of this Code, the medical assistance program shall,
1278	1278	23 subject to appropriation and federal approval, also reimburse
1279	1279	24 hospitals for costs associated with all newborn screening
1280	1280	25 tests added on and after August 9, 2024 (the effective date of
1281	1281	26 Public Act 103-909) this amendatory Act of the 103rd General
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
1287	1287	HB1504 - 35 - LRB104 08529 KTG 18581 b
1288	1288
1289	1289
1290	1290	HB1504- 36 -LRB104 08529 KTG 18581 b HB1504 - 36 - LRB104 08529 KTG 18581 b
1291	1291	HB1504 - 36 - LRB104 08529 KTG 18581 b
1292	1292	1 Assembly to the Newborn Metabolic Screening Act and required
1293	1293	2 to be performed under that Act at a rate not less than the fee
1294	1294	3 charged by the Department of Public Health. The Department
1295	1295	4 shall seek federal approval before the implementation of the
1296	1296	5 newborn screening test fees by the Department of Public
1297	1297	6 Health.
1298	1298	7 Notwithstanding any other provision of this Code,
1299	1299	8 beginning on January 1, 2024, subject to federal approval,
1300	1300	9 cognitive assessment and care planning services provided to a
1301	1301	10 person who experiences signs or symptoms of cognitive
1302	1302	11 impairment, as defined by the Diagnostic and Statistical
1303	1303	12 Manual of Mental Disorders, Fifth Edition, shall be covered
1304	1304	13 under the medical assistance program for persons who are
1305	1305	14 otherwise eligible for medical assistance under this Article.
1306	1306	15 Notwithstanding any other provision of this Code,
1307	1307	16 medically necessary reconstructive services that are intended
1308	1308	17 to restore physical appearance shall be covered under the
1309	1309	18 medical assistance program for persons who are otherwise
1310	1310	19 eligible for medical assistance under this Article. As used in
1311	1311	20 this paragraph, "reconstructive services" means treatments
1312	1312	21 performed on structures of the body damaged by trauma to
1313	1313	22 restore physical appearance.
1314	1314	23 No later than July 1, 2025, over-the-counter choline
1315	1315	24 dietary supplements for pregnant persons shall be covered
1316	1316	25 under the medical assistance program.
1317	1317	26 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1318	1318
1319	1319
1320	1320
1321	1321
1322	1322
1323	1323	HB1504 - 36 - LRB104 08529 KTG 18581 b
1324	1324
1325	1325
1326	1326	HB1504- 37 -LRB104 08529 KTG 18581 b HB1504 - 37 - LRB104 08529 KTG 18581 b
1327	1327	HB1504 - 37 - LRB104 08529 KTG 18581 b
1328	1328	1 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1329	1329	2 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1330	1330	3 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1331	1331	4 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1332	1332	5 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1333	1333	6 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1334	1334	7 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1335	1335	8 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1336	1336	9 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
1337	1337	10 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
1338	1338	11 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
1339	1339	12 10-10-24.)
1340	1340	13 (Text of Section after amendment by P.A. 103-808)
1341	1341	14 Sec. 5-5. Medical services. The Illinois Department, by
1342	1342	15 rule, shall determine the quantity and quality of and the rate
1343	1343	16 of reimbursement for the medical assistance for which payment
1344	1344	17 will be authorized, and the medical services to be provided,
1345	1345	18 which may include all or part of the following: (1) inpatient
1346	1346	19 hospital services; (2) outpatient hospital services; (3) other
1347	1347	20 laboratory and X-ray services; (4) skilled nursing home
1348	1348	21 services; (5) physicians' services whether furnished in the
1349	1349	22 office, the patient's home, a hospital, a skilled nursing
1350	1350	23 home, or elsewhere; (6) medical care, or any other type of
1351	1351	24 remedial care furnished by licensed practitioners; (7) home
1352	1352	25 health care services; (8) private duty nursing service; (9)
1353	1353
1354	1354
1355	1355
1356	1356
1357	1357
1358	1358	HB1504 - 37 - LRB104 08529 KTG 18581 b
1359	1359
1360	1360
1361	1361	HB1504- 38 -LRB104 08529 KTG 18581 b HB1504 - 38 - LRB104 08529 KTG 18581 b
1362	1362	HB1504 - 38 - LRB104 08529 KTG 18581 b
1363	1363	1 clinic services; (10) dental services, including prevention
1364	1364	2 and treatment of periodontal disease and dental caries disease
1365	1365	3 for pregnant individuals, provided by an individual licensed
1366	1366	4 to practice dentistry or dental surgery; for purposes of this
1367	1367	5 item (10), "dental services" means diagnostic, preventive, or
1368	1368	6 corrective procedures provided by or under the supervision of
1369	1369	7 a dentist in the practice of his or her profession; (11)
1370	1370	8 physical therapy and related services; (12) prescribed drugs,
1371	1371	9 dentures, and prosthetic devices; and eyeglasses prescribed by
1372	1372	10 a physician skilled in the diseases of the eye, or by an
1373	1373	11 optometrist, whichever the person may select; (13) other
1374	1374	12 diagnostic, screening, preventive, and rehabilitative
1375	1375	13 services, including to ensure that the individual's need for
1376	1376	14 intervention or treatment of mental disorders or substance use
1377	1377	15 disorders or co-occurring mental health and substance use
1378	1378	16 disorders is determined using a uniform screening, assessment,
1379	1379	17 and evaluation process inclusive of criteria, for children and
1380	1380	18 adults; for purposes of this item (13), a uniform screening,
1381	1381	19 assessment, and evaluation process refers to a process that
1382	1382	20 includes an appropriate evaluation and, as warranted, a
1383	1383	21 referral; "uniform" does not mean the use of a singular
1384	1384	22 instrument, tool, or process that all must utilize; (14)
1385	1385	23 transportation and such other expenses as may be necessary;
1386	1386	24 (15) medical treatment of sexual assault survivors, as defined
1387	1387	25 in Section 1a of the Sexual Assault Survivors Emergency
1388	1388	26 Treatment Act, for injuries sustained as a result of the
1389	1389
1390	1390
1391	1391
1392	1392
1393	1393
1394	1394	HB1504 - 38 - LRB104 08529 KTG 18581 b
1395	1395
1396	1396
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1398	1398	HB1504 - 39 - LRB104 08529 KTG 18581 b
1399	1399	1 sexual assault, including examinations and laboratory tests to
1400	1400	2 discover evidence which may be used in criminal proceedings
1401	1401	3 arising from the sexual assault; (16) the diagnosis and
1402	1402	4 treatment of sickle cell anemia; (16.5) services performed by
1403	1403	5 a chiropractic physician licensed under the Medical Practice
1404	1404	6 Act of 1987 and acting within the scope of his or her license,
1405	1405	7 including, but not limited to, chiropractic manipulative
1406	1406	8 treatment; and (17) any other medical care, and any other type
1407	1407	9 of remedial care recognized under the laws of this State. The
1408	1408	10 term "any other type of remedial care" shall include nursing
1409	1409	11 care and nursing home service for persons who rely on
1410	1410	12 treatment by spiritual means alone through prayer for healing.
1411	1411	13 Notwithstanding any other provision of this Section, a
1412	1412	14 comprehensive tobacco use cessation program that includes
1413	1413	15 purchasing prescription drugs or prescription medical devices
1414	1414	16 approved by the Food and Drug Administration shall be covered
1415	1415	17 under the medical assistance program under this Article for
1416	1416	18 persons who are otherwise eligible for assistance under this
1417	1417	19 Article.
1418	1418	20 Notwithstanding any other provision of this Code,
1419	1419	21 reproductive health care that is otherwise legal in Illinois
1420	1420	22 shall be covered under the medical assistance program for
1421	1421	23 persons who are otherwise eligible for medical assistance
1422	1422	24 under this Article.
1423	1423	25 Notwithstanding any other provision of this Section, all
1424	1424	26 tobacco cessation medications approved by the United States
1425	1425
1426	1426
1427	1427
1428	1428
1429	1429
1430	1430	HB1504 - 39 - LRB104 08529 KTG 18581 b
1431	1431
1432	1432
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1434	1434	HB1504 - 40 - LRB104 08529 KTG 18581 b
1435	1435	1 Food and Drug Administration and all individual and group
1436	1436	2 tobacco cessation counseling services and telephone-based
1437	1437	3 counseling services and tobacco cessation medications provided
1438	1438	4 through the Illinois Tobacco Quitline shall be covered under
1439	1439	5 the medical assistance program for persons who are otherwise
1440	1440	6 eligible for assistance under this Article. The Department
1441	1441	7 shall comply with all federal requirements necessary to obtain
1442	1442	8 federal financial participation, as specified in 42 CFR
1443	1443	9 433.15(b)(7), for telephone-based counseling services provided
1444	1444	10 through the Illinois Tobacco Quitline, including, but not
1445	1445	11 limited to: (i) entering into a memorandum of understanding or
1446	1446	12 interagency agreement with the Department of Public Health, as
1447	1447	13 administrator of the Illinois Tobacco Quitline; and (ii)
1448	1448	14 developing a cost allocation plan for Medicaid-allowable
1449	1449	15 Illinois Tobacco Quitline services in accordance with 45 CFR
1450	1450	16 95.507. The Department shall submit the memorandum of
1451	1451	17 understanding or interagency agreement, the cost allocation
1452	1452	18 plan, and all other necessary documentation to the Centers for
1453	1453	19 Medicare and Medicaid Services for review and approval.
1454	1454	20 Coverage under this paragraph shall be contingent upon federal
1455	1455	21 approval.
1456	1456	22 Notwithstanding any other provision of this Code, the
1457	1457	23 Illinois Department may not require, as a condition of payment
1458	1458	24 for any laboratory test authorized under this Article, that a
1459	1459	25 physician's handwritten signature appear on the laboratory
1460	1460	26 test order form. The Illinois Department may, however, impose
1461	1461
1462	1462
1463	1463
1464	1464
1465	1465
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1467	1467
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1471	1471	1 other appropriate requirements regarding laboratory test order
1472	1472	2 documentation.
1473	1473	3 Upon receipt of federal approval of an amendment to the
1474	1474	4 Illinois Title XIX State Plan for this purpose, the Department
1475	1475	5 shall authorize the Chicago Public Schools (CPS) to procure a
1476	1476	6 vendor or vendors to manufacture eyeglasses for individuals
1477	1477	7 enrolled in a school within the CPS system. CPS shall ensure
1478	1478	8 that its vendor or vendors are enrolled as providers in the
1479	1479	9 medical assistance program and in any capitated Medicaid
1480	1480	10 managed care entity (MCE) serving individuals enrolled in a
1481	1481	11 school within the CPS system. Under any contract procured
1482	1482	12 under this provision, the vendor or vendors must serve only
1483	1483	13 individuals enrolled in a school within the CPS system. Claims
1484	1484	14 for services provided by CPS's vendor or vendors to recipients
1485	1485	15 of benefits in the medical assistance program under this Code,
1486	1486	16 the Children's Health Insurance Program, or the Covering ALL
1487	1487	17 KIDS Health Insurance Program shall be submitted to the
1488	1488	18 Department or the MCE in which the individual is enrolled for
1489	1489	19 payment and shall be reimbursed at the Department's or the
1490	1490	20 MCE's established rates or rate methodologies for eyeglasses.
1491	1491	21 On and after July 1, 2012, the Department of Healthcare
1492	1492	22 and Family Services may provide the following services to
1493	1493	23 persons eligible for assistance under this Article who are
1494	1494	24 participating in education, training or employment programs
1495	1495	25 operated by the Department of Human Services as successor to
1496	1496	26 the Department of Public Aid:
1497	1497
1498	1498
1499	1499
1500	1500
1501	1501
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1503	1503
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1507	1507	1 (1) dental services provided by or under the
1508	1508	2 supervision of a dentist; and
1509	1509	3 (2) eyeglasses prescribed by a physician skilled in
1510	1510	4 the diseases of the eye, or by an optometrist, whichever
1511	1511	5 the person may select.
1512	1512	6 On and after July 1, 2018, the Department of Healthcare
1513	1513	7 and Family Services shall provide dental services to any adult
1514	1514	8 who is otherwise eligible for assistance under the medical
1515	1515	9 assistance program. As used in this paragraph, "dental
1516	1516	10 services" means diagnostic, preventative, restorative, or
1517	1517	11 corrective procedures, including procedures and services for
1518	1518	12 the prevention and treatment of periodontal disease and dental
1519	1519	13 caries disease, provided by an individual who is licensed to
1520	1520	14 practice dentistry or dental surgery or who is under the
1521	1521	15 supervision of a dentist in the practice of his or her
1522	1522	16 profession.
1523	1523	17 On and after July 1, 2018, targeted dental services, as
1524	1524	18 set forth in Exhibit D of the Consent Decree entered by the
1525	1525	19 United States District Court for the Northern District of
1526	1526	20 Illinois, Eastern Division, in the matter of Memisovski v.
1527	1527	21 Maram, Case No. 92 C 1982, that are provided to adults under
1528	1528	22 the medical assistance program shall be established at no less
1529	1529	23 than the rates set forth in the "New Rate" column in Exhibit D
1530	1530	24 of the Consent Decree for targeted dental services that are
1531	1531	25 provided to persons under the age of 18 under the medical
1532	1532	26 assistance program.
1533	1533
1534	1534
1535	1535
1536	1536
1537	1537
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1539	1539
1540	1540
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1543	1543	1 Subject to federal approval, on and after January 1, 2025,
1544	1544	2 the rates paid for sedation evaluation and the provision of
1545	1545	3 deep sedation and intravenous sedation for the purpose of
1546	1546	4 dental services shall be increased by 33% above the rates in
1547	1547	5 effect on December 31, 2024. The rates paid for nitrous oxide
1548	1548	6 sedation shall not be impacted by this paragraph and shall
1549	1549	7 remain the same as the rates in effect on December 31, 2024.
1550	1550	8 Notwithstanding any other provision of this Code and
1551	1551	9 subject to federal approval, the Department may adopt rules to
1552	1552	10 allow a dentist who is volunteering his or her service at no
1553	1553	11 cost to render dental services through an enrolled
1554	1554	12 not-for-profit health clinic without the dentist personally
1555	1555	13 enrolling as a participating provider in the medical
1556	1556	14 assistance program. A not-for-profit health clinic shall
1557	1557	15 include a public health clinic or Federally Qualified Health
1558	1558	16 Center or other enrolled provider, as determined by the
1559	1559	17 Department, through which dental services covered under this
1560	1560	18 Section are performed. The Department shall establish a
1561	1561	19 process for payment of claims for reimbursement for covered
1562	1562	20 dental services rendered under this provision.
1563	1563	21 Subject to appropriation and to federal approval, the
1564	1564	22 Department shall file administrative rules updating the
1565	1565	23 Handicapping Labio-Lingual Deviation orthodontic scoring tool
1566	1566	24 by January 1, 2025, or as soon as practicable.
1567	1567	25 On and after January 1, 2022, the Department of Healthcare
1568	1568	26 and Family Services shall administer and regulate a
1569	1569
1570	1570
1571	1571
1572	1572
1573	1573
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1575	1575
1576	1576
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1579	1579	1 school-based dental program that allows for the out-of-office
1580	1580	2 delivery of preventative dental services in a school setting
1581	1581	3 to children under 19 years of age. The Department shall
1582	1582	4 establish, by rule, guidelines for participation by providers
1583	1583	5 and set requirements for follow-up referral care based on the
1584	1584	6 requirements established in the Dental Office Reference Manual
1585	1585	7 published by the Department that establishes the requirements
1586	1586	8 for dentists participating in the All Kids Dental School
1587	1587	9 Program. Every effort shall be made by the Department when
1588	1588	10 developing the program requirements to consider the different
1589	1589	11 geographic differences of both urban and rural areas of the
1590	1590	12 State for initial treatment and necessary follow-up care. No
1591	1591	13 provider shall be charged a fee by any unit of local government
1592	1592	14 to participate in the school-based dental program administered
1593	1593	15 by the Department. Nothing in this paragraph shall be
1594	1594	16 construed to limit or preempt a home rule unit's or school
1595	1595	17 district's authority to establish, change, or administer a
1596	1596	18 school-based dental program in addition to, or independent of,
1597	1597	19 the school-based dental program administered by the
1598	1598	20 Department.
1599	1599	21 The Illinois Department, by rule, may distinguish and
1600	1600	22 classify the medical services to be provided only in
1601	1601	23 accordance with the classes of persons designated in Section
1602	1602	24 5-2.
1603	1603	25 The Department of Healthcare and Family Services must
1604	1604	26 provide coverage and reimbursement for amino acid-based
1605	1605
1606	1606
1607	1607
1608	1608
1609	1609
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1611	1611
1612	1612
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1615	1615	1 elemental formulas, regardless of delivery method, for the
1616	1616	2 diagnosis and treatment of (i) eosinophilic disorders and (ii)
1617	1617	3 short bowel syndrome when the prescribing physician has issued
1618	1618	4 a written order stating that the amino acid-based elemental
1619	1619	5 formula is medically necessary.
1620	1620	6 The Illinois Department shall authorize the provision of,
1621	1621	7 and shall authorize payment for, screening by low-dose
1622	1622	8 mammography for the presence of occult breast cancer for
1623	1623	9 individuals 35 years of age or older who are eligible for
1624	1624	10 medical assistance under this Article, as follows:
1625	1625	11 (A) A baseline mammogram for individuals 35 to 39
1626	1626	12 years of age.
1627	1627	13 (B) An annual mammogram for individuals 40 years of
1628	1628	14 age or older.
1629	1629	15 (C) A mammogram at the age and intervals considered
1630	1630	16 medically necessary by the individual's health care
1631	1631	17 provider for individuals under 40 years of age and having
1632	1632	18 a family history of breast cancer, prior personal history
1633	1633	19 of breast cancer, positive genetic testing, or other risk
1634	1634	20 factors.
1635	1635	21 (D) A comprehensive ultrasound screening and MRI of an
1636	1636	22 entire breast or breasts if a mammogram demonstrates
1637	1637	23 heterogeneous or dense breast tissue or when medically
1638	1638	24 necessary as determined by a physician licensed to
1639	1639	25 practice medicine in all of its branches.
1640	1640	26 (E) A screening MRI when medically necessary, as
1641	1641
1642	1642
1643	1643
1644	1644
1645	1645
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1647	1647
1648	1648
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1651	1651	1 determined by a physician licensed to practice medicine in
1652	1652	2 all of its branches.
1653	1653	3 (F) A diagnostic mammogram when medically necessary,
1654	1654	4 as determined by a physician licensed to practice medicine
1655	1655	5 in all its branches, advanced practice registered nurse,
1656	1656	6 or physician assistant.
1657	1657	7 (G) Molecular breast imaging (MBI) and MRI of an
1658	1658	8 entire breast or breasts if a mammogram demonstrates
1659	1659	9 heterogeneous or dense breast tissue or when medically
1660	1660	10 necessary as determined by a physician licensed to
1661	1661	11 practice medicine in all of its branches, advanced
1662	1662	12 practice registered nurse, or physician assistant.
1663	1663	13 The Department shall not impose a deductible, coinsurance,
1664	1664	14 copayment, or any other cost-sharing requirement on the
1665	1665	15 coverage provided under this paragraph; except that this
1666	1666	16 sentence does not apply to coverage of diagnostic mammograms
1667	1667	17 to the extent such coverage would disqualify a high-deductible
1668	1668	18 health plan from eligibility for a health savings account
1669	1669	19 pursuant to Section 223 of the Internal Revenue Code (26
1670	1670	20 U.S.C. 223).
1671	1671	21 All screenings shall include a physical breast exam,
1672	1672	22 instruction on self-examination and information regarding the
1673	1673	23 frequency of self-examination and its value as a preventative
1674	1674	24 tool.
1675	1675	25 For purposes of this Section:
1676	1676	26 "Diagnostic mammogram" means a mammogram obtained using
1677	1677
1678	1678
1679	1679
1680	1680
1681	1681
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1683	1683
1684	1684
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1687	1687	1 diagnostic mammography.
1688	1688	2 "Diagnostic mammography" means a method of screening that
1689	1689	3 is designed to evaluate an abnormality in a breast, including
1690	1690	4 an abnormality seen or suspected on a screening mammogram or a
1691	1691	5 subjective or objective abnormality otherwise detected in the
1692	1692	6 breast.
1693	1693	7 "Low-dose mammography" means the x-ray examination of the
1694	1694	8 breast using equipment dedicated specifically for mammography,
1695	1695	9 including the x-ray tube, filter, compression device, and
1696	1696	10 image receptor, with an average radiation exposure delivery of
1697	1697	11 less than one rad per breast for 2 views of an average size
1698	1698	12 breast. The term also includes digital mammography and
1699	1699	13 includes breast tomosynthesis.
1700	1700	14 "Breast tomosynthesis" means a radiologic procedure that
1701	1701	15 involves the acquisition of projection images over the
1702	1702	16 stationary breast to produce cross-sectional digital
1703	1703	17 three-dimensional images of the breast.
1704	1704	18 If, at any time, the Secretary of the United States
1705	1705	19 Department of Health and Human Services, or its successor
1706	1706	20 agency, promulgates rules or regulations to be published in
1707	1707	21 the Federal Register or publishes a comment in the Federal
1708	1708	22 Register or issues an opinion, guidance, or other action that
1709	1709	23 would require the State, pursuant to any provision of the
1710	1710	24 Patient Protection and Affordable Care Act (Public Law
1711	1711	25 111-148), including, but not limited to, 42 U.S.C.
1712	1712	26 18031(d)(3)(B) or any successor provision, to defray the cost
1713	1713
1714	1714
1715	1715
1716	1716
1717	1717
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1719	1719
1720	1720
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1723	1723	1 of any coverage for breast tomosynthesis outlined in this
1724	1724	2 paragraph, then the requirement that an insurer cover breast
1725	1725	3 tomosynthesis is inoperative other than any such coverage
1726	1726	4 authorized under Section 1902 of the Social Security Act, 42
1727	1727	5 U.S.C. 1396a, and the State shall not assume any obligation
1728	1728	6 for the cost of coverage for breast tomosynthesis set forth in
1729	1729	7 this paragraph.
1730	1730	8 On and after January 1, 2016, the Department shall ensure
1731	1731	9 that all networks of care for adult clients of the Department
1732	1732	10 include access to at least one breast imaging Center of
1733	1733	11 Imaging Excellence as certified by the American College of
1734	1734	12 Radiology.
1735	1735	13 On and after January 1, 2012, providers participating in a
1736	1736	14 quality improvement program approved by the Department shall
1737	1737	15 be reimbursed for screening and diagnostic mammography at the
1738	1738	16 same rate as the Medicare program's rates, including the
1739	1739	17 increased reimbursement for digital mammography and, after
1740	1740	18 January 1, 2023 (the effective date of Public Act 102-1018),
1741	1741	19 breast tomosynthesis.
1742	1742	20 The Department shall convene an expert panel including
1743	1743	21 representatives of hospitals, free-standing mammography
1744	1744	22 facilities, and doctors, including radiologists, to establish
1745	1745	23 quality standards for mammography.
1746	1746	24 On and after January 1, 2017, providers participating in a
1747	1747	25 breast cancer treatment quality improvement program approved
1748	1748	26 by the Department shall be reimbursed for breast cancer
1749	1749
1750	1750
1751	1751
1752	1752
1753	1753
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1755	1755
1756	1756
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1759	1759	1 treatment at a rate that is no lower than 95% of the Medicare
1760	1760	2 program's rates for the data elements included in the breast
1761	1761	3 cancer treatment quality program.
1762	1762	4 The Department shall convene an expert panel, including
1763	1763	5 representatives of hospitals, free-standing breast cancer
1764	1764	6 treatment centers, breast cancer quality organizations, and
1765	1765	7 doctors, including radiologists that are trained in all forms
1766	1766	8 of FDA-approved FDA approved breast imaging technologies,
1767	1767	9 breast surgeons, reconstructive breast surgeons, oncologists,
1768	1768	10 and primary care providers to establish quality standards for
1769	1769	11 breast cancer treatment.
1770	1770	12 Subject to federal approval, the Department shall
1771	1771	13 establish a rate methodology for mammography at federally
1772	1772	14 qualified health centers and other encounter-rate clinics.
1773	1773	15 These clinics or centers may also collaborate with other
1774	1774	16 hospital-based mammography facilities. By January 1, 2016, the
1775	1775	17 Department shall report to the General Assembly on the status
1776	1776	18 of the provision set forth in this paragraph.
1777	1777	19 The Department shall establish a methodology to remind
1778	1778	20 individuals who are age-appropriate for screening mammography,
1779	1779	21 but who have not received a mammogram within the previous 18
1780	1780	22 months, of the importance and benefit of screening
1781	1781	23 mammography. The Department shall work with experts in breast
1782	1782	24 cancer outreach and patient navigation to optimize these
1783	1783	25 reminders and shall establish a methodology for evaluating
1784	1784	26 their effectiveness and modifying the methodology based on the
1785	1785
1786	1786
1787	1787
1788	1788
1789	1789
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1791	1791
1792	1792
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1794	1794	HB1504 - 50 - LRB104 08529 KTG 18581 b
1795	1795	1 evaluation.
1796	1796	2 The Department shall establish a performance goal for
1797	1797	3 primary care providers with respect to their female patients
1798	1798	4 over age 40 receiving an annual mammogram. This performance
1799	1799	5 goal shall be used to provide additional reimbursement in the
1800	1800	6 form of a quality performance bonus to primary care providers
1801	1801	7 who meet that goal.
1802	1802	8 The Department shall devise a means of case-managing or
1803	1803	9 patient navigation for beneficiaries diagnosed with breast
1804	1804	10 cancer. This program shall initially operate as a pilot
1805	1805	11 program in areas of the State with the highest incidence of
1806	1806	12 mortality related to breast cancer. At least one pilot program
1807	1807	13 site shall be in the metropolitan Chicago area and at least one
1808	1808	14 site shall be outside the metropolitan Chicago area. On or
1809	1809	15 after July 1, 2016, the pilot program shall be expanded to
1810	1810	16 include one site in western Illinois, one site in southern
1811	1811	17 Illinois, one site in central Illinois, and 4 sites within
1812	1812	18 metropolitan Chicago. An evaluation of the pilot program shall
1813	1813	19 be carried out measuring health outcomes and cost of care for
1814	1814	20 those served by the pilot program compared to similarly
1815	1815	21 situated patients who are not served by the pilot program.
1816	1816	22 The Department shall require all networks of care to
1817	1817	23 develop a means either internally or by contract with experts
1818	1818	24 in navigation and community outreach to navigate cancer
1819	1819	25 patients to comprehensive care in a timely fashion. The
1820	1820	26 Department shall require all networks of care to include
1821	1821
1822	1822
1823	1823
1824	1824
1825	1825
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1827	1827
1828	1828
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1830	1830	HB1504 - 51 - LRB104 08529 KTG 18581 b
1831	1831	1 access for patients diagnosed with cancer to at least one
1832	1832	2 academic commission on cancer-accredited cancer program as an
1833	1833	3 in-network covered benefit.
1834	1834	4 The Department shall provide coverage and reimbursement
1835	1835	5 for a human papillomavirus (HPV) vaccine that is approved for
1836	1836	6 marketing by the federal Food and Drug Administration for all
1837	1837	7 persons between the ages of 9 and 45. Subject to federal
1838	1838	8 approval, the Department shall provide coverage and
1839	1839	9 reimbursement for a human papillomavirus (HPV) vaccine for
1840	1840	10 persons of the age of 46 and above who have been diagnosed with
1841	1841	11 cervical dysplasia with a high risk of recurrence or
1842	1842	12 progression. The Department shall disallow any
1843	1843	13 preauthorization requirements for the administration of the
1844	1844	14 human papillomavirus (HPV) vaccine.
1845	1845	15 On or after July 1, 2022, individuals who are otherwise
1846	1846	16 eligible for medical assistance under this Article shall
1847	1847	17 receive coverage for perinatal depression screenings for the
1848	1848	18 12-month period beginning on the last day of their pregnancy.
1849	1849	19 Medical assistance coverage under this paragraph shall be
1850	1850	20 conditioned on the use of a screening instrument approved by
1851	1851	21 the Department.
1852	1852	22 Any medical or health care provider shall immediately
1853	1853	23 recommend, to any pregnant individual who is being provided
1854	1854	24 prenatal services and is suspected of having a substance use
1855	1855	25 disorder as defined in the Substance Use Disorder Act,
1856	1856	26 referral to a local substance use disorder treatment program
1857	1857
1858	1858
1859	1859
1860	1860
1861	1861
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1863	1863
1864	1864
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1867	1867	1 licensed by the Department of Human Services or to a licensed
1868	1868	2 hospital which provides substance abuse treatment services.
1869	1869	3 The Department of Healthcare and Family Services shall assure
1870	1870	4 coverage for the cost of treatment of the drug abuse or
1871	1871	5 addiction for pregnant recipients in accordance with the
1872	1872	6 Illinois Medicaid Program in conjunction with the Department
1873	1873	7 of Human Services.
1874	1874	8 All medical providers providing medical assistance to
1875	1875	9 pregnant individuals under this Code shall receive information
1876	1876	10 from the Department on the availability of services under any
1877	1877	11 program providing case management services for addicted
1878	1878	12 individuals, including information on appropriate referrals
1879	1879	13 for other social services that may be needed by addicted
1880	1880	14 individuals in addition to treatment for addiction.
1881	1881	15 The Illinois Department, in cooperation with the
1882	1882	16 Departments of Human Services (as successor to the Department
1883	1883	17 of Alcoholism and Substance Abuse) and Public Health, through
1884	1884	18 a public awareness campaign, may provide information
1885	1885	19 concerning treatment for alcoholism and drug abuse and
1886	1886	20 addiction, prenatal health care, and other pertinent programs
1887	1887	21 directed at reducing the number of drug-affected infants born
1888	1888	22 to recipients of medical assistance.
1889	1889	23 Neither the Department of Healthcare and Family Services
1890	1890	24 nor the Department of Human Services shall sanction the
1891	1891	25 recipient solely on the basis of the recipient's substance
1892	1892	26 abuse.
1893	1893
1894	1894
1895	1895
1896	1896
1897	1897
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1899	1899
1900	1900
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1903	1903	1 The Illinois Department shall establish such regulations
1904	1904	2 governing the dispensing of health services under this Article
1905	1905	3 as it shall deem appropriate. The Department should seek the
1906	1906	4 advice of formal professional advisory committees appointed by
1907	1907	5 the Director of the Illinois Department for the purpose of
1908	1908	6 providing regular advice on policy and administrative matters,
1909	1909	7 information dissemination and educational activities for
1910	1910	8 medical and health care providers, and consistency in
1911	1911	9 procedures to the Illinois Department.
1912	1912	10 The Illinois Department may develop and contract with
1913	1913	11 Partnerships of medical providers to arrange medical services
1914	1914	12 for persons eligible under Section 5-2 of this Code.
1915	1915	13 Implementation of this Section may be by demonstration
1916	1916	14 projects in certain geographic areas. The Partnership shall be
1917	1917	15 represented by a sponsor organization. The Department, by
1918	1918	16 rule, shall develop qualifications for sponsors of
1919	1919	17 Partnerships. Nothing in this Section shall be construed to
1920	1920	18 require that the sponsor organization be a medical
1921	1921	19 organization.
1922	1922	20 The sponsor must negotiate formal written contracts with
1923	1923	21 medical providers for physician services, inpatient and
1924	1924	22 outpatient hospital care, home health services, treatment for
1925	1925	23 alcoholism and substance abuse, and other services determined
1926	1926	24 necessary by the Illinois Department by rule for delivery by
1927	1927	25 Partnerships. Physician services must include prenatal and
1928	1928	26 obstetrical care. The Illinois Department shall reimburse
1929	1929
1930	1930
1931	1931
1932	1932
1933	1933
1934	1934	HB1504 - 53 - LRB104 08529 KTG 18581 b
1935	1935
1936	1936
1937	1937	HB1504- 54 -LRB104 08529 KTG 18581 b HB1504 - 54 - LRB104 08529 KTG 18581 b
1938	1938	HB1504 - 54 - LRB104 08529 KTG 18581 b
1939	1939	1 medical services delivered by Partnership providers to clients
1940	1940	2 in target areas according to provisions of this Article and
1941	1941	3 the Illinois Health Finance Reform Act, except that:
1942	1942	4 (1) Physicians participating in a Partnership and
1943	1943	5 providing certain services, which shall be determined by
1944	1944	6 the Illinois Department, to persons in areas covered by
1945	1945	7 the Partnership may receive an additional surcharge for
1946	1946	8 such services.
1947	1947	9 (2) The Department may elect to consider and negotiate
1948	1948	10 financial incentives to encourage the development of
1949	1949	11 Partnerships and the efficient delivery of medical care.
1950	1950	12 (3) Persons receiving medical services through
1951	1951	13 Partnerships may receive medical and case management
1952	1952	14 services above the level usually offered through the
1953	1953	15 medical assistance program.
1954	1954	16 Medical providers shall be required to meet certain
1955	1955	17 qualifications to participate in Partnerships to ensure the
1956	1956	18 delivery of high quality medical services. These
1957	1957	19 qualifications shall be determined by rule of the Illinois
1958	1958	20 Department and may be higher than qualifications for
1959	1959	21 participation in the medical assistance program. Partnership
1960	1960	22 sponsors may prescribe reasonable additional qualifications
1961	1961	23 for participation by medical providers, only with the prior
1962	1962	24 written approval of the Illinois Department.
1963	1963	25 Nothing in this Section shall limit the free choice of
1964	1964	26 practitioners, hospitals, and other providers of medical
1965	1965
1966	1966
1967	1967
1968	1968
1969	1969
1970	1970	HB1504 - 54 - LRB104 08529 KTG 18581 b
1971	1971
1972	1972
1973	1973	HB1504- 55 -LRB104 08529 KTG 18581 b HB1504 - 55 - LRB104 08529 KTG 18581 b
1974	1974	HB1504 - 55 - LRB104 08529 KTG 18581 b
1975	1975	1 services by clients. In order to ensure patient freedom of
1976	1976	2 choice, the Illinois Department shall immediately promulgate
1977	1977	3 all rules and take all other necessary actions so that
1978	1978	4 provided services may be accessed from therapeutically
1979	1979	5 certified optometrists to the full extent of the Illinois
1980	1980	6 Optometric Practice Act of 1987 without discriminating between
1981	1981	7 service providers.
1982	1982	8 The Department shall apply for a waiver from the United
1983	1983	9 States Health Care Financing Administration to allow for the
1984	1984	10 implementation of Partnerships under this Section.
1985	1985	11 The Illinois Department shall require health care
1986	1986	12 providers to maintain records that document the medical care
1987	1987	13 and services provided to recipients of Medical Assistance
1988	1988	14 under this Article. Such records must be retained for a period
1989	1989	15 of not less than 6 years from the date of service or as
1990	1990	16 provided by applicable State law, whichever period is longer,
1991	1991	17 except that if an audit is initiated within the required
1992	1992	18 retention period then the records must be retained until the
1993	1993	19 audit is completed and every exception is resolved. The
1994	1994	20 Illinois Department shall require health care providers to
1995	1995	21 make available, when authorized by the patient, in writing,
1996	1996	22 the medical records in a timely fashion to other health care
1997	1997	23 providers who are treating or serving persons eligible for
1998	1998	24 Medical Assistance under this Article. All dispensers of
1999	1999	25 medical services shall be required to maintain and retain
2000	2000	26 business and professional records sufficient to fully and
2001	2001
2002	2002
2003	2003
2004	2004
2005	2005
2006	2006	HB1504 - 55 - LRB104 08529 KTG 18581 b
2007	2007
2008	2008
2009	2009	HB1504- 56 -LRB104 08529 KTG 18581 b HB1504 - 56 - LRB104 08529 KTG 18581 b
2010	2010	HB1504 - 56 - LRB104 08529 KTG 18581 b
2011	2011	1 accurately document the nature, scope, details and receipt of
2012	2012	2 the health care provided to persons eligible for medical
2013	2013	3 assistance under this Code, in accordance with regulations
2014	2014	4 promulgated by the Illinois Department. The rules and
2015	2015	5 regulations shall require that proof of the receipt of
2016	2016	6 prescription drugs, dentures, prosthetic devices and
2017	2017	7 eyeglasses by eligible persons under this Section accompany
2018	2018	8 each claim for reimbursement submitted by the dispenser of
2019	2019	9 such medical services. No such claims for reimbursement shall
2020	2020	10 be approved for payment by the Illinois Department without
2021	2021	11 such proof of receipt, unless the Illinois Department shall
2022	2022	12 have put into effect and shall be operating a system of
2023	2023	13 post-payment audit and review which shall, on a sampling
2024	2024	14 basis, be deemed adequate by the Illinois Department to assure
2025	2025	15 that such drugs, dentures, prosthetic devices and eyeglasses
2026	2026	16 for which payment is being made are actually being received by
2027	2027	17 eligible recipients. Within 90 days after September 16, 1984
2028	2028	18 (the effective date of Public Act 83-1439), the Illinois
2029	2029	19 Department shall establish a current list of acquisition costs
2030	2030	20 for all prosthetic devices and any other items recognized as
2031	2031	21 medical equipment and supplies reimbursable under this Article
2032	2032	22 and shall update such list on a quarterly basis, except that
2033	2033	23 the acquisition costs of all prescription drugs shall be
2034	2034	24 updated no less frequently than every 30 days as required by
2035	2035	25 Section 5-5.12.
2036	2036	26 Notwithstanding any other law to the contrary, the
2037	2037
2038	2038
2039	2039
2040	2040
2041	2041
2042	2042	HB1504 - 56 - LRB104 08529 KTG 18581 b
2043	2043
2044	2044
2045	2045	HB1504- 57 -LRB104 08529 KTG 18581 b HB1504 - 57 - LRB104 08529 KTG 18581 b
2046	2046	HB1504 - 57 - LRB104 08529 KTG 18581 b
2047	2047	1 Illinois Department shall, within 365 days after July 22, 2013
2048	2048	2 (the effective date of Public Act 98-104), establish
2049	2049	3 procedures to permit skilled care facilities licensed under
2050	2050	4 the Nursing Home Care Act to submit monthly billing claims for
2051	2051	5 reimbursement purposes. Following development of these
2052	2052	6 procedures, the Department shall, by July 1, 2016, test the
2053	2053	7 viability of the new system and implement any necessary
2054	2054	8 operational or structural changes to its information
2055	2055	9 technology platforms in order to allow for the direct
2056	2056	10 acceptance and payment of nursing home claims.
2057	2057	11 Notwithstanding any other law to the contrary, the
2058	2058	12 Illinois Department shall, within 365 days after August 15,
2059	2059	13 2014 (the effective date of Public Act 98-963), establish
2060	2060	14 procedures to permit ID/DD facilities licensed under the ID/DD
2061	2061	15 Community Care Act and MC/DD facilities licensed under the
2062	2062	16 MC/DD Act to submit monthly billing claims for reimbursement
2063	2063	17 purposes. Following development of these procedures, the
2064	2064	18 Department shall have an additional 365 days to test the
2065	2065	19 viability of the new system and to ensure that any necessary
2066	2066	20 operational or structural changes to its information
2067	2067	21 technology platforms are implemented.
2068	2068	22 The Illinois Department shall require all dispensers of
2069	2069	23 medical services, other than an individual practitioner or
2070	2070	24 group of practitioners, desiring to participate in the Medical
2071	2071	25 Assistance program established under this Article to disclose
2072	2072	26 all financial, beneficial, ownership, equity, surety or other
2073	2073
2074	2074
2075	2075
2076	2076
2077	2077
2078	2078	HB1504 - 57 - LRB104 08529 KTG 18581 b
2079	2079
2080	2080
2081	2081	HB1504- 58 -LRB104 08529 KTG 18581 b HB1504 - 58 - LRB104 08529 KTG 18581 b
2082	2082	HB1504 - 58 - LRB104 08529 KTG 18581 b
2083	2083	1 interests in any and all firms, corporations, partnerships,
2084	2084	2 associations, business enterprises, joint ventures, agencies,
2085	2085	3 institutions or other legal entities providing any form of
2086	2086	4 health care services in this State under this Article.
2087	2087	5 The Illinois Department may require that all dispensers of
2088	2088	6 medical services desiring to participate in the medical
2089	2089	7 assistance program established under this Article disclose,
2090	2090	8 under such terms and conditions as the Illinois Department may
2091	2091	9 by rule establish, all inquiries from clients and attorneys
2092	2092	10 regarding medical bills paid by the Illinois Department, which
2093	2093	11 inquiries could indicate potential existence of claims or
2094	2094	12 liens for the Illinois Department.
2095	2095	13 Enrollment of a vendor shall be subject to a provisional
2096	2096	14 period and shall be conditional for one year. During the
2097	2097	15 period of conditional enrollment, the Department may terminate
2098	2098	16 the vendor's eligibility to participate in, or may disenroll
2099	2099	17 the vendor from, the medical assistance program without cause.
2100	2100	18 Unless otherwise specified, such termination of eligibility or
2101	2101	19 disenrollment is not subject to the Department's hearing
2102	2102	20 process. However, a disenrolled vendor may reapply without
2103	2103	21 penalty.
2104	2104	22 The Department has the discretion to limit the conditional
2105	2105	23 enrollment period for vendors based upon the category of risk
2106	2106	24 of the vendor.
2107	2107	25 Prior to enrollment and during the conditional enrollment
2108	2108	26 period in the medical assistance program, all vendors shall be
2109	2109
2110	2110
2111	2111
2112	2112
2113	2113
2114	2114	HB1504 - 58 - LRB104 08529 KTG 18581 b
2115	2115
2116	2116
2117	2117	HB1504- 59 -LRB104 08529 KTG 18581 b HB1504 - 59 - LRB104 08529 KTG 18581 b
2118	2118	HB1504 - 59 - LRB104 08529 KTG 18581 b
2119	2119	1 subject to enhanced oversight, screening, and review based on
2120	2120	2 the risk of fraud, waste, and abuse that is posed by the
2121	2121	3 category of risk of the vendor. The Illinois Department shall
2122	2122	4 establish the procedures for oversight, screening, and review,
2123	2123	5 which may include, but need not be limited to: criminal and
2124	2124	6 financial background checks; fingerprinting; license,
2125	2125	7 certification, and authorization verifications; unscheduled or
2126	2126	8 unannounced site visits; database checks; prepayment audit
2127	2127	9 reviews; audits; payment caps; payment suspensions; and other
2128	2128	10 screening as required by federal or State law.
2129	2129	11 The Department shall define or specify the following: (i)
2130	2130	12 by provider notice, the "category of risk of the vendor" for
2131	2131	13 each type of vendor, which shall take into account the level of
2132	2132	14 screening applicable to a particular category of vendor under
2133	2133	15 federal law and regulations; (ii) by rule or provider notice,
2134	2134	16 the maximum length of the conditional enrollment period for
2135	2135	17 each category of risk of the vendor; and (iii) by rule, the
2136	2136	18 hearing rights, if any, afforded to a vendor in each category
2137	2137	19 of risk of the vendor that is terminated or disenrolled during
2138	2138	20 the conditional enrollment period.
2139	2139	21 To be eligible for payment consideration, a vendor's
2140	2140	22 payment claim or bill, either as an initial claim or as a
2141	2141	23 resubmitted claim following prior rejection, must be received
2142	2142	24 by the Illinois Department, or its fiscal intermediary, no
2143	2143	25 later than 180 days after the latest date on the claim on which
2144	2144	26 medical goods or services were provided, with the following
2145	2145
2146	2146
2147	2147
2148	2148
2149	2149
2150	2150	HB1504 - 59 - LRB104 08529 KTG 18581 b
2151	2151
2152	2152
2153	2153	HB1504- 60 -LRB104 08529 KTG 18581 b HB1504 - 60 - LRB104 08529 KTG 18581 b
2154	2154	HB1504 - 60 - LRB104 08529 KTG 18581 b
2155	2155	1 exceptions:
2156	2156	2 (1) In the case of a provider whose enrollment is in
2157	2157	3 process by the Illinois Department, the 180-day period
2158	2158	4 shall not begin until the date on the written notice from
2159	2159	5 the Illinois Department that the provider enrollment is
2160	2160	6 complete.
2161	2161	7 (2) In the case of errors attributable to the Illinois
2162	2162	8 Department or any of its claims processing intermediaries
2163	2163	9 which result in an inability to receive, process, or
2164	2164	10 adjudicate a claim, the 180-day period shall not begin
2165	2165	11 until the provider has been notified of the error.
2166	2166	12 (3) In the case of a provider for whom the Illinois
2167	2167	13 Department initiates the monthly billing process.
2168	2168	14 (4) In the case of a provider operated by a unit of
2169	2169	15 local government with a population exceeding 3,000,000
2170	2170	16 when local government funds finance federal participation
2171	2171	17 for claims payments.
2172	2172	18 For claims for services rendered during a period for which
2173	2173	19 a recipient received retroactive eligibility, claims must be
2174	2174	20 filed within 180 days after the Department determines the
2175	2175	21 applicant is eligible. For claims for which the Illinois
2176	2176	22 Department is not the primary payer, claims must be submitted
2177	2177	23 to the Illinois Department within 180 days after the final
2178	2178	24 adjudication by the primary payer.
2179	2179	25 In the case of long term care facilities, within 120
2180	2180	26 calendar days of receipt by the facility of required
2181	2181
2182	2182
2183	2183
2184	2184
2185	2185
2186	2186	HB1504 - 60 - LRB104 08529 KTG 18581 b
2187	2187
2188	2188
2189	2189	HB1504- 61 -LRB104 08529 KTG 18581 b HB1504 - 61 - LRB104 08529 KTG 18581 b
2190	2190	HB1504 - 61 - LRB104 08529 KTG 18581 b
2191	2191	1 prescreening information, new admissions with associated
2192	2192	2 admission documents shall be submitted through the Medical
2193	2193	3 Electronic Data Interchange (MEDI) or the Recipient
2194	2194	4 Eligibility Verification (REV) System or shall be submitted
2195	2195	5 directly to the Department of Human Services using required
2196	2196	6 admission forms. Effective September 1, 2014, admission
2197	2197	7 documents, including all prescreening information, must be
2198	2198	8 submitted through MEDI or REV. Confirmation numbers assigned
2199	2199	9 to an accepted transaction shall be retained by a facility to
2200	2200	10 verify timely submittal. Once an admission transaction has
2201	2201	11 been completed, all resubmitted claims following prior
2202	2202	12 rejection are subject to receipt no later than 180 days after
2203	2203	13 the admission transaction has been completed.
2204	2204	14 Claims that are not submitted and received in compliance
2205	2205	15 with the foregoing requirements shall not be eligible for
2206	2206	16 payment under the medical assistance program, and the State
2207	2207	17 shall have no liability for payment of those claims.
2208	2208	18 To the extent consistent with applicable information and
2209	2209	19 privacy, security, and disclosure laws, State and federal
2210	2210	20 agencies and departments shall provide the Illinois Department
2211	2211	21 access to confidential and other information and data
2212	2212	22 necessary to perform eligibility and payment verifications and
2213	2213	23 other Illinois Department functions. This includes, but is not
2214	2214	24 limited to: information pertaining to licensure;
2215	2215	25 certification; earnings; immigration status; citizenship; wage
2216	2216	26 reporting; unearned and earned income; pension income;
2217	2217
2218	2218
2219	2219
2220	2220
2221	2221
2222	2222	HB1504 - 61 - LRB104 08529 KTG 18581 b
2223	2223
2224	2224
2225	2225	HB1504- 62 -LRB104 08529 KTG 18581 b HB1504 - 62 - LRB104 08529 KTG 18581 b
2226	2226	HB1504 - 62 - LRB104 08529 KTG 18581 b
2227	2227	1 employment; supplemental security income; social security
2228	2228	2 numbers; National Provider Identifier (NPI) numbers; the
2229	2229	3 National Practitioner Data Bank (NPDB); program and agency
2230	2230	4 exclusions; taxpayer identification numbers; tax delinquency;
2231	2231	5 corporate information; and death records.
2232	2232	6 The Illinois Department shall enter into agreements with
2233	2233	7 State agencies and departments, and is authorized to enter
2234	2234	8 into agreements with federal agencies and departments, under
2235	2235	9 which such agencies and departments shall share data necessary
2236	2236	10 for medical assistance program integrity functions and
2237	2237	11 oversight. The Illinois Department shall develop, in
2238	2238	12 cooperation with other State departments and agencies, and in
2239	2239	13 compliance with applicable federal laws and regulations,
2240	2240	14 appropriate and effective methods to share such data. At a
2241	2241	15 minimum, and to the extent necessary to provide data sharing,
2242	2242	16 the Illinois Department shall enter into agreements with State
2243	2243	17 agencies and departments, and is authorized to enter into
2244	2244	18 agreements with federal agencies and departments, including,
2245	2245	19 but not limited to: the Secretary of State; the Department of
2246	2246	20 Revenue; the Department of Public Health; the Department of
2247	2247	21 Human Services; and the Department of Financial and
2248	2248	22 Professional Regulation.
2249	2249	23 Beginning in fiscal year 2013, the Illinois Department
2250	2250	24 shall set forth a request for information to identify the
2251	2251	25 benefits of a pre-payment, post-adjudication, and post-edit
2252	2252	26 claims system with the goals of streamlining claims processing
2253	2253
2254	2254
2255	2255
2256	2256
2257	2257
2258	2258	HB1504 - 62 - LRB104 08529 KTG 18581 b
2259	2259
2260	2260
2261	2261	HB1504- 63 -LRB104 08529 KTG 18581 b HB1504 - 63 - LRB104 08529 KTG 18581 b
2262	2262	HB1504 - 63 - LRB104 08529 KTG 18581 b
2263	2263	1 and provider reimbursement, reducing the number of pending or
2264	2264	2 rejected claims, and helping to ensure a more transparent
2265	2265	3 adjudication process through the utilization of: (i) provider
2266	2266	4 data verification and provider screening technology; and (ii)
2267	2267	5 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
2268	2268	6 post-adjudicated predictive modeling with an integrated case
2269	2269	7 management system with link analysis. Such a request for
2270	2270	8 information shall not be considered as a request for proposal
2271	2271	9 or as an obligation on the part of the Illinois Department to
2272	2272	10 take any action or acquire any products or services.
2273	2273	11 The Illinois Department shall establish policies,
2274	2274	12 procedures, standards and criteria by rule for the
2275	2275	13 acquisition, repair and replacement of orthotic and prosthetic
2276	2276	14 devices and durable medical equipment. Such rules shall
2277	2277	15 provide, but not be limited to, the following services: (1)
2278	2278	16 immediate repair or replacement of such devices by recipients;
2279	2279	17 and (2) rental, lease, purchase or lease-purchase of durable
2280	2280	18 medical equipment in a cost-effective manner, taking into
2281	2281	19 consideration the recipient's medical prognosis, the extent of
2282	2282	20 the recipient's needs, and the requirements and costs for
2283	2283	21 maintaining such equipment. Subject to prior approval, such
2284	2284	22 rules shall enable a recipient to temporarily acquire and use
2285	2285	23 alternative or substitute devices or equipment pending repairs
2286	2286	24 or replacements of any device or equipment previously
2287	2287	25 authorized for such recipient by the Department.
2288	2288	26 Notwithstanding any provision of Section 5-5f to the contrary,
2289	2289
2290	2290
2291	2291
2292	2292
2293	2293
2294	2294	HB1504 - 63 - LRB104 08529 KTG 18581 b
2295	2295
2296	2296
2297	2297	HB1504- 64 -LRB104 08529 KTG 18581 b HB1504 - 64 - LRB104 08529 KTG 18581 b
2298	2298	HB1504 - 64 - LRB104 08529 KTG 18581 b
2299	2299	1 the Department may, by rule, exempt certain replacement
2300	2300	2 wheelchair parts from prior approval and, for wheelchairs,
2301	2301	3 wheelchair parts, wheelchair accessories, and related seating
2302	2302	4 and positioning items, determine the wholesale price by
2303	2303	5 methods other than actual acquisition costs.
2304	2304	6 The Department shall require, by rule, all providers of
2305	2305	7 durable medical equipment to be accredited by an accreditation
2306	2306	8 organization approved by the federal Centers for Medicare and
2307	2307	9 Medicaid Services and recognized by the Department in order to
2308	2308	10 bill the Department for providing durable medical equipment to
2309	2309	11 recipients. No later than 15 months after the effective date
2310	2310	12 of the rule adopted pursuant to this paragraph, all providers
2311	2311	13 must meet the accreditation requirement.
2312	2312	14 In order to promote environmental responsibility, meet the
2313	2313	15 needs of recipients and enrollees, and achieve significant
2314	2314	16 cost savings, the Department, or a managed care organization
2315	2315	17 under contract with the Department, may provide recipients or
2316	2316	18 managed care enrollees who have a prescription or Certificate
2317	2317	19 of Medical Necessity access to refurbished durable medical
2318	2318	20 equipment under this Section (excluding prosthetic and
2319	2319	21 orthotic devices as defined in the Orthotics, Prosthetics, and
2320	2320	22 Pedorthics Practice Act and complex rehabilitation technology
2321	2321	23 products and associated services) through the State's
2322	2322	24 assistive technology program's reutilization program, using
2323	2323	25 staff with the Assistive Technology Professional (ATP)
2324	2324	26 Certification if the refurbished durable medical equipment:
2325	2325
2326	2326
2327	2327
2328	2328
2329	2329
2330	2330	HB1504 - 64 - LRB104 08529 KTG 18581 b
2331	2331
2332	2332
2333	2333	HB1504- 65 -LRB104 08529 KTG 18581 b HB1504 - 65 - LRB104 08529 KTG 18581 b
2334	2334	HB1504 - 65 - LRB104 08529 KTG 18581 b
2335	2335	1 (i) is available; (ii) is less expensive, including shipping
2336	2336	2 costs, than new durable medical equipment of the same type;
2337	2337	3 (iii) is able to withstand at least 3 years of use; (iv) is
2338	2338	4 cleaned, disinfected, sterilized, and safe in accordance with
2339	2339	5 federal Food and Drug Administration regulations and guidance
2340	2340	6 governing the reprocessing of medical devices in health care
2341	2341	7 settings; and (v) equally meets the needs of the recipient or
2342	2342	8 enrollee. The reutilization program shall confirm that the
2343	2343	9 recipient or enrollee is not already in receipt of the same or
2344	2344	10 similar equipment from another service provider, and that the
2345	2345	11 refurbished durable medical equipment equally meets the needs
2346	2346	12 of the recipient or enrollee. Nothing in this paragraph shall
2347	2347	13 be construed to limit recipient or enrollee choice to obtain
2348	2348	14 new durable medical equipment or place any additional prior
2349	2349	15 authorization conditions on enrollees of managed care
2350	2350	16 organizations.
2351	2351	17 The Department shall execute, relative to the nursing home
2352	2352	18 prescreening project, written inter-agency agreements with the
2353	2353	19 Department of Human Services and the Department on Aging, to
2354	2354	20 effect the following: (i) intake procedures and common
2355	2355	21 eligibility criteria for those persons who are receiving
2356	2356	22 non-institutional services; and (ii) the establishment and
2357	2357	23 development of non-institutional services in areas of the
2358	2358	24 State where they are not currently available or are
2359	2359	25 undeveloped; and (iii) notwithstanding any other provision of
2360	2360	26 law, subject to federal approval, on and after July 1, 2012, an
2361	2361
2362	2362
2363	2363
2364	2364
2365	2365
2366	2366	HB1504 - 65 - LRB104 08529 KTG 18581 b
2367	2367
2368	2368
2369	2369	HB1504- 66 -LRB104 08529 KTG 18581 b HB1504 - 66 - LRB104 08529 KTG 18581 b
2370	2370	HB1504 - 66 - LRB104 08529 KTG 18581 b
2371	2371	1 increase in the determination of need (DON) scores from 29 to
2372	2372	2 37 for applicants for institutional and home and
2373	2373	3 community-based long term care; if and only if federal
2374	2374	4 approval is not granted, the Department may, in conjunction
2375	2375	5 with other affected agencies, implement utilization controls
2376	2376	6 or changes in benefit packages to effectuate a similar savings
2377	2377	7 amount for this population; and (iv) no later than July 1,
2378	2378	8 2013, minimum level of care eligibility criteria for
2379	2379	9 institutional and home and community-based long term care; and
2380	2380	10 (v) no later than October 1, 2013, establish procedures to
2381	2381	11 permit long term care providers access to eligibility scores
2382	2382	12 for individuals with an admission date who are seeking or
2383	2383	13 receiving services from the long term care provider. In order
2384	2384	14 to select the minimum level of care eligibility criteria, the
2385	2385	15 Governor shall establish a workgroup that includes affected
2386	2386	16 agency representatives and stakeholders representing the
2387	2387	17 institutional and home and community-based long term care
2388	2388	18 interests. This Section shall not restrict the Department from
2389	2389	19 implementing lower level of care eligibility criteria for
2390	2390	20 community-based services in circumstances where federal
2391	2391	21 approval has been granted.
2392	2392	22 The Illinois Department shall develop and operate, in
2393	2393	23 cooperation with other State Departments and agencies and in
2394	2394	24 compliance with applicable federal laws and regulations,
2395	2395	25 appropriate and effective systems of health care evaluation
2396	2396	26 and programs for monitoring of utilization of health care
2397	2397
2398	2398
2399	2399
2400	2400
2401	2401
2402	2402	HB1504 - 66 - LRB104 08529 KTG 18581 b
2403	2403
2404	2404
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2406	2406	HB1504 - 67 - LRB104 08529 KTG 18581 b
2407	2407	1 services and facilities, as it affects persons eligible for
2408	2408	2 medical assistance under this Code.
2409	2409	3 The Illinois Department shall report annually to the
2410	2410	4 General Assembly, no later than the second Friday in April of
2411	2411	5 1979 and each year thereafter, in regard to:
2412	2412	6 (a) actual statistics and trends in utilization of
2413	2413	7 medical services by public aid recipients;
2414	2414	8 (b) actual statistics and trends in the provision of
2415	2415	9 the various medical services by medical vendors;
2416	2416	10 (c) current rate structures and proposed changes in
2417	2417	11 those rate structures for the various medical vendors; and
2418	2418	12 (d) efforts at utilization review and control by the
2419	2419	13 Illinois Department.
2420	2420	14 The period covered by each report shall be the 3 years
2421	2421	15 ending on the June 30 prior to the report. The report shall
2422	2422	16 include suggested legislation for consideration by the General
2423	2423	17 Assembly. The requirement for reporting to the General
2424	2424	18 Assembly shall be satisfied by filing copies of the report as
2425	2425	19 required by Section 3.1 of the General Assembly Organization
2426	2426	20 Act, and filing such additional copies with the State
2427	2427	21 Government Report Distribution Center for the General Assembly
2428	2428	22 as is required under paragraph (t) of Section 7 of the State
2429	2429	23 Library Act.
2430	2430	24 Rulemaking authority to implement Public Act 95-1045, if
2431	2431	25 any, is conditioned on the rules being adopted in accordance
2432	2432	26 with all provisions of the Illinois Administrative Procedure
2433	2433
2434	2434
2435	2435
2436	2436
2437	2437
2438	2438	HB1504 - 67 - LRB104 08529 KTG 18581 b
2439	2439
2440	2440
2441	2441	HB1504- 68 -LRB104 08529 KTG 18581 b HB1504 - 68 - LRB104 08529 KTG 18581 b
2442	2442	HB1504 - 68 - LRB104 08529 KTG 18581 b
2443	2443	1 Act and all rules and procedures of the Joint Committee on
2444	2444	2 Administrative Rules; any purported rule not so adopted, for
2445	2445	3 whatever reason, is unauthorized.
2446	2446	4 On and after July 1, 2012, the Department shall reduce any
2447	2447	5 rate of reimbursement for services or other payments or alter
2448	2448	6 any methodologies authorized by this Code to reduce any rate
2449	2449	7 of reimbursement for services or other payments in accordance
2450	2450	8 with Section 5-5e.
2451	2451	9 Because kidney transplantation can be an appropriate,
2452	2452	10 cost-effective alternative to renal dialysis when medically
2453	2453	11 necessary and notwithstanding the provisions of Section 1-11
2454	2454	12 of this Code, beginning October 1, 2014, the Department shall
2455	2455	13 cover kidney transplantation for noncitizens with end-stage
2456	2456	14 renal disease who are not eligible for comprehensive medical
2457	2457	15 benefits, who meet the residency requirements of Section 5-3
2458	2458	16 of this Code, and who would otherwise meet the financial
2459	2459	17 requirements of the appropriate class of eligible persons
2460	2460	18 under Section 5-2 of this Code. To qualify for coverage of
2461	2461	19 kidney transplantation, such person must be receiving
2462	2462	20 emergency renal dialysis services covered by the Department.
2463	2463	21 Providers under this Section shall be prior approved and
2464	2464	22 certified by the Department to perform kidney transplantation
2465	2465	23 and the services under this Section shall be limited to
2466	2466	24 services associated with kidney transplantation.
2467	2467	25 Notwithstanding any other provision of this Code to the
2468	2468	26 contrary, on or after July 1, 2015, all FDA-approved FDA
2469	2469
2470	2470
2471	2471
2472	2472
2473	2473
2474	2474	HB1504 - 68 - LRB104 08529 KTG 18581 b
2475	2475
2476	2476
2477	2477	HB1504- 69 -LRB104 08529 KTG 18581 b HB1504 - 69 - LRB104 08529 KTG 18581 b
2478	2478	HB1504 - 69 - LRB104 08529 KTG 18581 b
2479	2479	1 approved forms of medication assisted treatment prescribed for
2480	2480	2 the treatment of alcohol dependence or treatment of opioid
2481	2481	3 dependence shall be covered under both fee-for-service and
2482	2482	4 managed care medical assistance programs for persons who are
2483	2483	5 otherwise eligible for medical assistance under this Article
2484	2484	6 and shall not be subject to any (1) utilization control, other
2485	2485	7 than those established under the American Society of Addiction
2486	2486	8 Medicine patient placement criteria, (2) prior authorization
2487	2487	9 mandate, (3) lifetime restriction limit mandate, or (4)
2488	2488	10 limitations on dosage.
2489	2489	11 On or after July 1, 2015, opioid antagonists prescribed
2490	2490	12 for the treatment of an opioid overdose, including the
2491	2491	13 medication product, administration devices, and any pharmacy
2492	2492	14 fees or hospital fees related to the dispensing, distribution,
2493	2493	15 and administration of the opioid antagonist, shall be covered
2494	2494	16 under the medical assistance program for persons who are
2495	2495	17 otherwise eligible for medical assistance under this Article.
2496	2496	18 As used in this Section, "opioid antagonist" means a drug that
2497	2497	19 binds to opioid receptors and blocks or inhibits the effect of
2498	2498	20 opioids acting on those receptors, including, but not limited
2499	2499	21 to, naloxone hydrochloride or any other similarly acting drug
2500	2500	22 approved by the U.S. Food and Drug Administration. The
2501	2501	23 Department shall not impose a copayment on the coverage
2502	2502	24 provided for naloxone hydrochloride under the medical
2503	2503	25 assistance program.
2504	2504	26 Upon federal approval, the Department shall provide
2505	2505
2506	2506
2507	2507
2508	2508
2509	2509
2510	2510	HB1504 - 69 - LRB104 08529 KTG 18581 b
2511	2511
2512	2512
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2514	2514	HB1504 - 70 - LRB104 08529 KTG 18581 b
2515	2515	1 coverage and reimbursement for all drugs that are approved for
2516	2516	2 marketing by the federal Food and Drug Administration and that
2517	2517	3 are recommended by the federal Public Health Service or the
2518	2518	4 United States Centers for Disease Control and Prevention for
2519	2519	5 pre-exposure prophylaxis and related pre-exposure prophylaxis
2520	2520	6 services, including, but not limited to, HIV and sexually
2521	2521	7 transmitted infection screening, treatment for sexually
2522	2522	8 transmitted infections, medical monitoring, assorted labs, and
2523	2523	9 counseling to reduce the likelihood of HIV infection among
2524	2524	10 individuals who are not infected with HIV but who are at high
2525	2525	11 risk of HIV infection.
2526	2526	12 A federally qualified health center, as defined in Section
2527	2527	13 1905(l)(2)(B) of the federal Social Security Act, shall be
2528	2528	14 reimbursed by the Department in accordance with the federally
2529	2529	15 qualified health center's encounter rate for services provided
2530	2530	16 to medical assistance recipients that are performed by a
2531	2531	17 dental hygienist, as defined under the Illinois Dental
2532	2532	18 Practice Act, working under the general supervision of a
2533	2533	19 dentist and employed by a federally qualified health center.
2534	2534	20 Within 90 days after October 8, 2021 (the effective date
2535	2535	21 of Public Act 102-665), the Department shall seek federal
2536	2536	22 approval of a State Plan amendment to expand coverage for
2537	2537	23 family planning services that includes presumptive eligibility
2538	2538	24 to individuals whose income is at or below 208% of the federal
2539	2539	25 poverty level. Coverage under this Section shall be effective
2540	2540	26 beginning no later than December 1, 2022.
2541	2541
2542	2542
2543	2543
2544	2544
2545	2545
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2547	2547
2548	2548
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2550	2550	HB1504 - 71 - LRB104 08529 KTG 18581 b
2551	2551	1 Subject to approval by the federal Centers for Medicare
2552	2552	2 and Medicaid Services of a Title XIX State Plan amendment
2553	2553	3 electing the Program of All-Inclusive Care for the Elderly
2554	2554	4 (PACE) as a State Medicaid option, as provided for by Subtitle
2555	2555	5 I (commencing with Section 4801) of Title IV of the Balanced
2556	2556	6 Budget Act of 1997 (Public Law 105-33) and Part 460
2557	2557	7 (commencing with Section 460.2) of Subchapter E of Title 42 of
2558	2558	8 the Code of Federal Regulations, PACE program services shall
2559	2559	9 become a covered benefit of the medical assistance program,
2560	2560	10 subject to criteria established in accordance with all
2561	2561	11 applicable laws.
2562	2562	12 Notwithstanding any other provision of this Code,
2563	2563	13 community-based pediatric palliative care from a trained
2564	2564	14 interdisciplinary team shall be covered under the medical
2565	2565	15 assistance program as provided in Section 15 of the Pediatric
2566	2566	16 Palliative Care Act.
2567	2567	17 Notwithstanding any other provision of this Code, within
2568	2568	18 12 months after June 2, 2022 (the effective date of Public Act
2569	2569	19 102-1037) and subject to federal approval, acupuncture
2570	2570	20 services performed by an acupuncturist licensed under the
2571	2571	21 Acupuncture Practice Act who is acting within the scope of his
2572	2572	22 or her license shall be covered under the medical assistance
2573	2573	23 program. The Department shall apply for any federal waiver or
2574	2574	24 State Plan amendment, if required, to implement this
2575	2575	25 paragraph. The Department may adopt any rules, including
2576	2576	26 standards and criteria, necessary to implement this paragraph.
2577	2577
2578	2578
2579	2579
2580	2580
2581	2581
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2583	2583
2584	2584
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2587	2587	1 Notwithstanding any other provision of this Code, the
2588	2588	2 medical assistance program shall, subject to federal approval,
2589	2589	3 reimburse hospitals for costs associated with a newborn
2590	2590	4 screening test for the presence of metachromatic
2591	2591	5 leukodystrophy, as required under the Newborn Metabolic
2592	2592	6 Screening Act, at a rate not less than the fee charged by the
2593	2593	7 Department of Public Health. Notwithstanding any other
2594	2594	8 provision of this Code, the medical assistance program shall,
2595	2595	9 subject to appropriation and federal approval, also reimburse
2596	2596	10 hospitals for costs associated with all newborn screening
2597	2597	11 tests added on and after August 9, 2024 (the effective date of
2598	2598	12 Public Act 103-909) this amendatory Act of the 103rd General
2599	2599	13 Assembly to the Newborn Metabolic Screening Act and required
2600	2600	14 to be performed under that Act at a rate not less than the fee
2601	2601	15 charged by the Department of Public Health. The Department
2602	2602	16 shall seek federal approval before the implementation of the
2603	2603	17 newborn screening test fees by the Department of Public
2604	2604	18 Health.
2605	2605	19 Notwithstanding any other provision of this Code,
2606	2606	20 beginning on January 1, 2024, subject to federal approval,
2607	2607	21 cognitive assessment and care planning services provided to a
2608	2608	22 person who experiences signs or symptoms of cognitive
2609	2609	23 impairment, as defined by the Diagnostic and Statistical
2610	2610	24 Manual of Mental Disorders, Fifth Edition, shall be covered
2611	2611	25 under the medical assistance program for persons who are
2612	2612	26 otherwise eligible for medical assistance under this Article.
2613	2613
2614	2614
2615	2615
2616	2616
2617	2617
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2619	2619
2620	2620
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2623	2623	1 Notwithstanding any other provision of this Code,
2624	2624	2 medically necessary reconstructive services that are intended
2625	2625	3 to restore physical appearance shall be covered under the
2626	2626	4 medical assistance program for persons who are otherwise
2627	2627	5 eligible for medical assistance under this Article. As used in
2628	2628	6 this paragraph, "reconstructive services" means treatments
2629	2629	7 performed on structures of the body damaged by trauma to
2630	2630	8 restore physical appearance.
2631	2631	9 No later than July 1, 2025, over-the-counter choline
2632	2632	10 dietary supplements for pregnant persons shall be covered
2633	2633	11 under the medical assistance program.
2634	2634	12 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
2635	2635	13 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2636	2636	14 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
2637	2637	15 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
2638	2638	16 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
2639	2639	17 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
2640	2640	18 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
2641	2641	19 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
2642	2642	20 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
2643	2643	21 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
2644	2644	22 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
2645	2645	23 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
2646	2646	24 8-9-24; revised 10-10-24.)
2647	2647	25 Section 95. No acceleration or delay. Where this Act makes
2648	2648
2649	2649
2650	2650
2651	2651
2652	2652
2653	2653	HB1504 - 73 - LRB104 08529 KTG 18581 b
2654	2654
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2658	2658	1 changes in a statute that is represented in this Act by text
2659	2659	2 that is not yet or no longer in effect (for example, a Section
2660	2660	3 represented by multiple versions), the use of that text does
2661	2661	4 not accelerate or delay the taking effect of (i) the changes
2662	2662	5 made by this Act or (ii) provisions derived from any other
2663	2663	6 Public Act.
2664	2664
2665	2665
2666	2666
2667	2667
2668	2668
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