Illinois House Bill HB1504 Latest Draft

                            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
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
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.
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    LRB104 08529 KTG 18581 b
A BILL FOR
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1  AN ACT concerning public aid.
2  Be it enacted by the People of the State of Illinois,
3  represented in the General Assembly:
4  Section 5. The Illinois Public Aid Code is amended by
5  changing Section 5-5 as follows:
6  (305 ILCS 5/5-5)
7  (Text of Section before amendment by P.A. 103-808)
8  Sec. 5-5. Medical services.  The Illinois Department, by
9  rule, shall determine the quantity and quality of and the rate
10  of reimbursement for the medical assistance for which payment
11  will be authorized, and the medical services to be provided,
12  which may include all or part of the following: (1) inpatient
13  hospital services; (2) outpatient hospital services; (3) other
14  laboratory and X-ray services; (4) skilled nursing home
15  services; (5) physicians' services whether furnished in the
16  office, the patient's home, a hospital, a skilled nursing
17  home, or elsewhere; (6) medical care, or any other type of
18  remedial care furnished by licensed practitioners; (7) home
19  health care services; (8) private duty nursing service; (9)
20  clinic services; (10) dental services, including prevention
21  and treatment of periodontal disease and dental caries disease
22  for pregnant individuals, provided by an individual licensed
23  to practice dentistry or dental surgery; for purposes of this

 

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
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.
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A BILL FOR

 

 

305 ILCS 5/5-5



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1  item (10), "dental services" means diagnostic, preventive, or
2  corrective procedures provided by or under the supervision of
3  a dentist in the practice of his or her profession; (11)
4  physical therapy and related services; (12) prescribed drugs,
5  dentures, and prosthetic devices; and eyeglasses prescribed by
6  a physician skilled in the diseases of the eye, or by an
7  optometrist, whichever the person may select; (13) other
8  diagnostic, screening, preventive, and rehabilitative
9  services, including to ensure that the individual's need for
10  intervention or treatment of mental disorders or substance use
11  disorders or co-occurring mental health and substance use
12  disorders is determined using a uniform screening, assessment,
13  and evaluation process inclusive of criteria, for children and
14  adults; for purposes of this item (13), a uniform screening,
15  assessment, and evaluation process refers to a process that
16  includes an appropriate evaluation and, as warranted, a
17  referral; "uniform" does not mean the use of a singular
18  instrument, tool, or process that all must utilize; (14)
19  transportation and such other expenses as may be necessary;
20  (15) medical treatment of sexual assault survivors, as defined
21  in Section 1a of the Sexual Assault Survivors Emergency
22  Treatment Act, for injuries sustained as a result of the
23  sexual assault, including examinations and laboratory tests to
24  discover evidence which may be used in criminal proceedings
25  arising from the sexual assault; (16) the diagnosis and
26  treatment of sickle cell anemia; (16.5) services performed by

 

 

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1  a chiropractic physician licensed under the Medical Practice
2  Act of 1987 and acting within the scope of his or her license,
3  including, but not limited to, chiropractic manipulative
4  treatment; and (17) any other medical care, and any other type
5  of remedial care recognized under the laws of this State. The
6  term "any other type of remedial care" shall include nursing
7  care and nursing home service for persons who rely on
8  treatment by spiritual means alone through prayer for healing.
9  Notwithstanding any other provision of this Section, a
10  comprehensive tobacco use cessation program that includes
11  purchasing prescription drugs or prescription medical devices
12  approved by the Food and Drug Administration shall be covered
13  under the medical assistance program under this Article for
14  persons who are otherwise eligible for assistance under this
15  Article.
16  Notwithstanding any other provision of this Code,
17  reproductive health care that is otherwise legal in Illinois
18  shall be covered under the medical assistance program for
19  persons who are otherwise eligible for medical assistance
20  under this Article.
21  Notwithstanding any other provision of this Section, all
22  tobacco cessation medications approved by the United States
23  Food and Drug Administration and all individual and group
24  tobacco cessation counseling services and telephone-based
25  counseling services and tobacco cessation medications provided
26  through the Illinois Tobacco Quitline shall be covered under

 

 

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1  the medical assistance program for persons who are otherwise
2  eligible for assistance under this Article. The Department
3  shall comply with all federal requirements necessary to obtain
4  federal financial participation, as specified in 42 CFR
5  433.15(b)(7), for telephone-based counseling services provided
6  through the Illinois Tobacco Quitline, including, but not
7  limited to: (i) entering into a memorandum of understanding or
8  interagency agreement with the Department of Public Health, as
9  administrator of the Illinois Tobacco Quitline; and (ii)
10  developing a cost allocation plan for Medicaid-allowable
11  Illinois Tobacco Quitline services in accordance with 45 CFR
12  95.507. The Department shall submit the memorandum of
13  understanding or interagency agreement, the cost allocation
14  plan, and all other necessary documentation to the Centers for
15  Medicare and Medicaid Services for review and approval.
16  Coverage under this paragraph shall be contingent upon federal
17  approval.
18  Notwithstanding any other provision of this Code, the
19  Illinois Department may not require, as a condition of payment
20  for any laboratory test authorized under this Article, that a
21  physician's handwritten signature appear on the laboratory
22  test order form. The Illinois Department may, however, impose
23  other appropriate requirements regarding laboratory test order
24  documentation.
25  Upon receipt of federal approval of an amendment to the
26  Illinois Title XIX State Plan for this purpose, the Department

 

 

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1  shall authorize the Chicago Public Schools (CPS) to procure a
2  vendor or vendors to manufacture eyeglasses for individuals
3  enrolled in a school within the CPS system. CPS shall ensure
4  that its vendor or vendors are enrolled as providers in the
5  medical assistance program and in any capitated Medicaid
6  managed care entity (MCE) serving individuals enrolled in a
7  school within the CPS system. Under any contract procured
8  under this provision, the vendor or vendors must serve only
9  individuals enrolled in a school within the CPS system. Claims
10  for services provided by CPS's vendor or vendors to recipients
11  of benefits in the medical assistance program under this Code,
12  the Children's Health Insurance Program, or the Covering ALL
13  KIDS Health Insurance Program shall be submitted to the
14  Department or the MCE in which the individual is enrolled for
15  payment and shall be reimbursed at the Department's or the
16  MCE's established rates or rate methodologies for eyeglasses.
17  On and after July 1, 2012, the Department of Healthcare
18  and Family Services may provide the following services to
19  persons eligible for assistance under this Article who are
20  participating in education, training or employment programs
21  operated by the Department of Human Services as successor to
22  the Department of Public Aid:
23  (1) dental services provided by or under the
24  supervision of a dentist; and
25  (2) eyeglasses prescribed by a physician skilled in
26  the diseases of the eye, or by an optometrist, whichever

 

 

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1  the person may select.
2  On and after July 1, 2018, the Department of Healthcare
3  and Family Services shall provide dental services to any adult
4  who is otherwise eligible for assistance under the medical
5  assistance program. As used in this paragraph, "dental
6  services" means diagnostic, preventative, restorative, or
7  corrective procedures, including procedures and services for
8  the prevention and treatment of periodontal disease and dental
9  caries disease, provided by an individual who is licensed to
10  practice dentistry or dental surgery or who is under the
11  supervision of a dentist in the practice of his or her
12  profession.
13  On and after July 1, 2018, targeted dental services, as
14  set forth in Exhibit D of the Consent Decree entered by the
15  United States District Court for the Northern District of
16  Illinois, Eastern Division, in the matter of Memisovski v.
17  Maram, Case No. 92 C 1982, that are provided to adults under
18  the medical assistance program shall be established at no less
19  than the rates set forth in the "New Rate" column in Exhibit D
20  of the Consent Decree for targeted dental services that are
21  provided to persons under the age of 18 under the medical
22  assistance program.
23  Subject to federal approval, on and after January 1, 2025,
24  the rates paid for sedation evaluation and the provision of
25  deep sedation and intravenous sedation for the purpose of
26  dental services shall be increased by 33% above the rates in

 

 

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1  effect on December 31, 2024. The rates paid for nitrous oxide
2  sedation shall not be impacted by this paragraph and shall
3  remain the same as the rates in effect on December 31, 2024.
4  Notwithstanding any other provision of this Code and
5  subject to federal approval, the Department may adopt rules to
6  allow a dentist who is volunteering his or her service at no
7  cost to render dental services through an enrolled
8  not-for-profit health clinic without the dentist personally
9  enrolling as a participating provider in the medical
10  assistance program. A not-for-profit health clinic shall
11  include a public health clinic or Federally Qualified Health
12  Center or other enrolled provider, as determined by the
13  Department, through which dental services covered under this
14  Section are performed. The Department shall establish a
15  process for payment of claims for reimbursement for covered
16  dental services rendered under this provision.
17  Subject to appropriation and to federal approval, the
18  Department shall file administrative rules updating the
19  Handicapping Labio-Lingual Deviation orthodontic scoring tool
20  by January 1, 2025, or as soon as practicable.
21  On and after January 1, 2022, the Department of Healthcare
22  and Family Services shall administer and regulate a
23  school-based dental program that allows for the out-of-office
24  delivery of preventative dental services in a school setting
25  to children under 19 years of age. The Department shall
26  establish, by rule, guidelines for participation by providers

 

 

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1  and set requirements for follow-up referral care based on the
2  requirements established in the Dental Office Reference Manual
3  published by the Department that establishes the requirements
4  for dentists participating in the All Kids Dental School
5  Program. Every effort shall be made by the Department when
6  developing the program requirements to consider the different
7  geographic differences of both urban and rural areas of the
8  State for initial treatment and necessary follow-up care. No
9  provider shall be charged a fee by any unit of local government
10  to participate in the school-based dental program administered
11  by the Department. Nothing in this paragraph shall be
12  construed to limit or preempt a home rule unit's or school
13  district's authority to establish, change, or administer a
14  school-based dental program in addition to, or independent of,
15  the school-based dental program administered by the
16  Department.
17  The Illinois Department, by rule, may distinguish and
18  classify the medical services to be provided only in
19  accordance with the classes of persons designated in Section
20  5-2.
21  The Department of Healthcare and Family Services must
22  provide coverage and reimbursement for amino acid-based
23  elemental formulas, regardless of delivery method, for the
24  diagnosis and treatment of (i) eosinophilic disorders and (ii)
25  short bowel syndrome when the prescribing physician has issued
26  a written order stating that the amino acid-based elemental

 

 

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1  formula is medically necessary.
2  The Illinois Department shall authorize the provision of,
3  and shall authorize payment for, screening by low-dose
4  mammography for the presence of occult breast cancer for
5  individuals 35 years of age or older who are eligible for
6  medical assistance under this Article, as follows:
7  (A) A baseline mammogram for individuals 35 to 39
8  years of age.
9  (B) An annual mammogram for individuals 40 years of
10  age or older.
11  (C) A mammogram at the age and intervals considered
12  medically necessary by the individual's health care
13  provider for individuals under 40 years of age and having
14  a family history of breast cancer, prior personal history
15  of breast cancer, positive genetic testing, or other risk
16  factors.
17  (D) A comprehensive ultrasound screening and MRI of an
18  entire breast or breasts if a mammogram demonstrates
19  heterogeneous or dense breast tissue or when medically
20  necessary as determined by a physician licensed to
21  practice medicine in all of its branches.
22  (E) A screening MRI when medically necessary, as
23  determined by a physician licensed to practice medicine in
24  all of its branches.
25  (F) A diagnostic mammogram when medically necessary,
26  as determined by a physician licensed to practice medicine

 

 

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1  in all its branches, advanced practice registered nurse,
2  or physician assistant.
3  The Department shall not impose a deductible, coinsurance,
4  copayment, or any other cost-sharing requirement on the
5  coverage provided under this paragraph; except that this
6  sentence does not apply to coverage of diagnostic mammograms
7  to the extent such coverage would disqualify a high-deductible
8  health plan from eligibility for a health savings account
9  pursuant to Section 223 of the Internal Revenue Code (26
10  U.S.C. 223).
11  All screenings shall include a physical breast exam,
12  instruction on self-examination and information regarding the
13  frequency of self-examination and its value as a preventative
14  tool.
15  For purposes of this Section:
16  "Diagnostic mammogram" means a mammogram obtained using
17  diagnostic mammography.
18  "Diagnostic mammography" means a method of screening that
19  is designed to evaluate an abnormality in a breast, including
20  an abnormality seen or suspected on a screening mammogram or a
21  subjective or objective abnormality otherwise detected in the
22  breast.
23  "Low-dose mammography" means the x-ray examination of the
24  breast using equipment dedicated specifically for mammography,
25  including the x-ray tube, filter, compression device, and
26  image receptor, with an average radiation exposure delivery of

 

 

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1  less than one rad per breast for 2 views of an average size
2  breast. The term also includes digital mammography and
3  includes breast tomosynthesis.
4  "Breast tomosynthesis" means a radiologic procedure that
5  involves the acquisition of projection images over the
6  stationary breast to produce cross-sectional digital
7  three-dimensional images of the breast.
8  If, at any time, the Secretary of the United States
9  Department of Health and Human Services, or its successor
10  agency, promulgates rules or regulations to be published in
11  the Federal Register or publishes a comment in the Federal
12  Register or issues an opinion, guidance, or other action that
13  would require the State, pursuant to any provision of the
14  Patient Protection and Affordable Care Act (Public Law
15  111-148), including, but not limited to, 42 U.S.C.
16  18031(d)(3)(B) or any successor provision, to defray the cost
17  of any coverage for breast tomosynthesis outlined in this
18  paragraph, then the requirement that an insurer cover breast
19  tomosynthesis is inoperative other than any such coverage
20  authorized under Section 1902 of the Social Security Act, 42
21  U.S.C. 1396a, and the State shall not assume any obligation
22  for the cost of coverage for breast tomosynthesis set forth in
23  this paragraph.
24  On and after January 1, 2016, the Department shall ensure
25  that all networks of care for adult clients of the Department
26  include access to at least one breast imaging Center of

 

 

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1  Imaging Excellence as certified by the American College of
2  Radiology.
3  On and after January 1, 2012, providers participating in a
4  quality improvement program approved by the Department shall
5  be reimbursed for screening and diagnostic mammography at the
6  same rate as the Medicare program's rates, including the
7  increased reimbursement for digital mammography and, after
8  January 1, 2023 (the effective date of Public Act 102-1018),
9  breast tomosynthesis.
10  The Department shall convene an expert panel including
11  representatives of hospitals, free-standing mammography
12  facilities, and doctors, including radiologists, to establish
13  quality standards for mammography.
14  On and after January 1, 2017, providers participating in a
15  breast cancer treatment quality improvement program approved
16  by the Department shall be reimbursed for breast cancer
17  treatment at a rate that is no lower than 95% of the Medicare
18  program's rates for the data elements included in the breast
19  cancer treatment quality program.
20  The Department shall convene an expert panel, including
21  representatives of hospitals, free-standing breast cancer
22  treatment centers, breast cancer quality organizations, and
23  doctors, including breast surgeons, reconstructive breast
24  surgeons, oncologists, and primary care providers to establish
25  quality standards for breast cancer treatment.
26  Subject to federal approval, the Department shall

 

 

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1  establish a rate methodology for mammography at federally
2  qualified health centers and other encounter-rate clinics.
3  These clinics or centers may also collaborate with other
4  hospital-based mammography facilities. By January 1, 2016, the
5  Department shall report to the General Assembly on the status
6  of the provision set forth in this paragraph.
7  The Department shall establish a methodology to remind
8  individuals who are age-appropriate for screening mammography,
9  but who have not received a mammogram within the previous 18
10  months, of the importance and benefit of screening
11  mammography. The Department shall work with experts in breast
12  cancer outreach and patient navigation to optimize these
13  reminders and shall establish a methodology for evaluating
14  their effectiveness and modifying the methodology based on the
15  evaluation.
16  The Department shall establish a performance goal for
17  primary care providers with respect to their female patients
18  over age 40 receiving an annual mammogram. This performance
19  goal shall be used to provide additional reimbursement in the
20  form of a quality performance bonus to primary care providers
21  who meet that goal.
22  The Department shall devise a means of case-managing or
23  patient navigation for beneficiaries diagnosed with breast
24  cancer. This program shall initially operate as a pilot
25  program in areas of the State with the highest incidence of
26  mortality related to breast cancer. At least one pilot program

 

 

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1  site shall be in the metropolitan Chicago area and at least one
2  site shall be outside the metropolitan Chicago area. On or
3  after July 1, 2016, the pilot program shall be expanded to
4  include one site in western Illinois, one site in southern
5  Illinois, one site in central Illinois, and 4 sites within
6  metropolitan Chicago. An evaluation of the pilot program shall
7  be carried out measuring health outcomes and cost of care for
8  those served by the pilot program compared to similarly
9  situated patients who are not served by the pilot program.
10  The Department shall require all networks of care to
11  develop a means either internally or by contract with experts
12  in navigation and community outreach to navigate cancer
13  patients to comprehensive care in a timely fashion. The
14  Department shall require all networks of care to include
15  access for patients diagnosed with cancer to at least one
16  academic commission on cancer-accredited cancer program as an
17  in-network covered benefit.
18  The Department shall provide coverage and reimbursement
19  for a human papillomavirus (HPV) vaccine that is approved for
20  marketing by the federal Food and Drug Administration for all
21  persons between the ages of 9 and 45. Subject to federal
22  approval, the Department shall provide coverage and
23  reimbursement for a human papillomavirus (HPV) vaccine for
24  persons of the age of 46 and above who have been diagnosed with
25  cervical dysplasia with a high risk of recurrence or
26  progression. The Department shall disallow any

 

 

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1  preauthorization requirements for the administration of the
2  human papillomavirus (HPV) vaccine.
3  On or after July 1, 2022, individuals who are otherwise
4  eligible for medical assistance under this Article shall
5  receive coverage for perinatal depression screenings for the
6  12-month period beginning on the last day of their pregnancy.
7  Medical assistance coverage under this paragraph shall be
8  conditioned on the use of a screening instrument approved by
9  the Department.
10  Any medical or health care provider shall immediately
11  recommend, to any pregnant individual who is being provided
12  prenatal services and is suspected of having a substance use
13  disorder as defined in the Substance Use Disorder Act,
14  referral to a local substance use disorder treatment program
15  licensed by the Department of Human Services or to a licensed
16  hospital which provides substance abuse treatment services.
17  The Department of Healthcare and Family Services shall assure
18  coverage for the cost of treatment of the drug abuse or
19  addiction for pregnant recipients in accordance with the
20  Illinois Medicaid Program in conjunction with the Department
21  of Human Services.
22  All medical providers providing medical assistance to
23  pregnant individuals under this Code shall receive information
24  from the Department on the availability of services under any
25  program providing case management services for addicted
26  individuals, including information on appropriate referrals

 

 

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1  for other social services that may be needed by addicted
2  individuals in addition to treatment for addiction.
3  The Illinois Department, in cooperation with the
4  Departments of Human Services (as successor to the Department
5  of Alcoholism and Substance Abuse) and Public Health, through
6  a public awareness campaign, may provide information
7  concerning treatment for alcoholism and drug abuse and
8  addiction, prenatal health care, and other pertinent programs
9  directed at reducing the number of drug-affected infants born
10  to recipients of medical assistance.
11  Neither the Department of Healthcare and Family Services
12  nor the Department of Human Services shall sanction the
13  recipient solely on the basis of the recipient's substance
14  abuse.
15  The Illinois Department shall establish such regulations
16  governing the dispensing of health services under this Article
17  as it shall deem appropriate. The Department should seek the
18  advice of formal professional advisory committees appointed by
19  the Director of the Illinois Department for the purpose of
20  providing regular advice on policy and administrative matters,
21  information dissemination and educational activities for
22  medical and health care providers, and consistency in
23  procedures to the Illinois Department.
24  The Illinois Department may develop and contract with
25  Partnerships of medical providers to arrange medical services
26  for persons eligible under Section 5-2 of this Code.

 

 

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1  Implementation of this Section may be by demonstration
2  projects in certain geographic areas. The Partnership shall be
3  represented by a sponsor organization. The Department, by
4  rule, shall develop qualifications for sponsors of
5  Partnerships. Nothing in this Section shall be construed to
6  require that the sponsor organization be a medical
7  organization.
8  The sponsor must negotiate formal written contracts with
9  medical providers for physician services, inpatient and
10  outpatient hospital care, home health services, treatment for
11  alcoholism and substance abuse, and other services determined
12  necessary by the Illinois Department by rule for delivery by
13  Partnerships. Physician services must include prenatal and
14  obstetrical care. The Illinois Department shall reimburse
15  medical services delivered by Partnership providers to clients
16  in target areas according to provisions of this Article and
17  the Illinois Health Finance Reform Act, except that:
18  (1) Physicians participating in a Partnership and
19  providing certain services, which shall be determined by
20  the Illinois Department, to persons in areas covered by
21  the Partnership may receive an additional surcharge for
22  such services.
23  (2) The Department may elect to consider and negotiate
24  financial incentives to encourage the development of
25  Partnerships and the efficient delivery of medical care.
26  (3) Persons receiving medical services through

 

 

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1  Partnerships may receive medical and case management
2  services above the level usually offered through the
3  medical assistance program.
4  Medical providers shall be required to meet certain
5  qualifications to participate in Partnerships to ensure the
6  delivery of high quality medical services. These
7  qualifications shall be determined by rule of the Illinois
8  Department and may be higher than qualifications for
9  participation in the medical assistance program. Partnership
10  sponsors may prescribe reasonable additional qualifications
11  for participation by medical providers, only with the prior
12  written approval of the Illinois Department.
13  Nothing in this Section shall limit the free choice of
14  practitioners, hospitals, and other providers of medical
15  services by clients. In order to ensure patient freedom of
16  choice, the Illinois Department shall immediately promulgate
17  all rules and take all other necessary actions so that
18  provided services may be accessed from therapeutically
19  certified optometrists to the full extent of the Illinois
20  Optometric Practice Act of 1987 without discriminating between
21  service providers.
22  The Department shall apply for a waiver from the United
23  States Health Care Financing Administration to allow for the
24  implementation of Partnerships under this Section.
25  The Illinois Department shall require health care
26  providers to maintain records that document the medical care

 

 

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1  and services provided to recipients of Medical Assistance
2  under this Article. Such records must be retained for a period
3  of not less than 6 years from the date of service or as
4  provided by applicable State law, whichever period is longer,
5  except that if an audit is initiated within the required
6  retention period then the records must be retained until the
7  audit is completed and every exception is resolved. The
8  Illinois Department shall require health care providers to
9  make available, when authorized by the patient, in writing,
10  the medical records in a timely fashion to other health care
11  providers who are treating or serving persons eligible for
12  Medical Assistance under this Article. All dispensers of
13  medical services shall be required to maintain and retain
14  business and professional records sufficient to fully and
15  accurately document the nature, scope, details and receipt of
16  the health care provided to persons eligible for medical
17  assistance under this Code, in accordance with regulations
18  promulgated by the Illinois Department. The rules and
19  regulations shall require that proof of the receipt of
20  prescription drugs, dentures, prosthetic devices and
21  eyeglasses by eligible persons under this Section accompany
22  each claim for reimbursement submitted by the dispenser of
23  such medical services. No such claims for reimbursement shall
24  be approved for payment by the Illinois Department without
25  such proof of receipt, unless the Illinois Department shall
26  have put into effect and shall be operating a system of

 

 

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1  post-payment audit and review which shall, on a sampling
2  basis, be deemed adequate by the Illinois Department to assure
3  that such drugs, dentures, prosthetic devices and eyeglasses
4  for which payment is being made are actually being received by
5  eligible recipients. Within 90 days after September 16, 1984
6  (the effective date of Public Act 83-1439), the Illinois
7  Department shall establish a current list of acquisition costs
8  for all prosthetic devices and any other items recognized as
9  medical equipment and supplies reimbursable under this Article
10  and shall update such list on a quarterly basis, except that
11  the acquisition costs of all prescription drugs shall be
12  updated no less frequently than every 30 days as required by
13  Section 5-5.12.
14  Notwithstanding any other law to the contrary, the
15  Illinois Department shall, within 365 days after July 22, 2013
16  (the effective date of Public Act 98-104), establish
17  procedures to permit skilled care facilities licensed under
18  the Nursing Home Care Act to submit monthly billing claims for
19  reimbursement purposes. Following development of these
20  procedures, the Department shall, by July 1, 2016, test the
21  viability of the new system and implement any necessary
22  operational or structural changes to its information
23  technology platforms in order to allow for the direct
24  acceptance and payment of nursing home claims.
25  Notwithstanding any other law to the contrary, the
26  Illinois Department shall, within 365 days after August 15,

 

 

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1  2014 (the effective date of Public Act 98-963), establish
2  procedures to permit ID/DD facilities licensed under the ID/DD
3  Community Care Act and MC/DD facilities licensed under the
4  MC/DD Act to submit monthly billing claims for reimbursement
5  purposes. Following development of these procedures, the
6  Department shall have an additional 365 days to test the
7  viability of the new system and to ensure that any necessary
8  operational or structural changes to its information
9  technology platforms are implemented.
10  The Illinois Department shall require all dispensers of
11  medical services, other than an individual practitioner or
12  group of practitioners, desiring to participate in the Medical
13  Assistance program established under this Article to disclose
14  all financial, beneficial, ownership, equity, surety or other
15  interests in any and all firms, corporations, partnerships,
16  associations, business enterprises, joint ventures, agencies,
17  institutions or other legal entities providing any form of
18  health care services in this State under this Article.
19  The Illinois Department may require that all dispensers of
20  medical services desiring to participate in the medical
21  assistance program established under this Article disclose,
22  under such terms and conditions as the Illinois Department may
23  by rule establish, all inquiries from clients and attorneys
24  regarding medical bills paid by the Illinois Department, which
25  inquiries could indicate potential existence of claims or
26  liens for the Illinois Department.

 

 

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1  Enrollment of a vendor shall be subject to a provisional
2  period and shall be conditional for one year. During the
3  period of conditional enrollment, the Department may terminate
4  the vendor's eligibility to participate in, or may disenroll
5  the vendor from, the medical assistance program without cause.
6  Unless otherwise specified, such termination of eligibility or
7  disenrollment is not subject to the Department's hearing
8  process. However, a disenrolled vendor may reapply without
9  penalty.
10  The Department has the discretion to limit the conditional
11  enrollment period for vendors based upon the category of risk
12  of the vendor.
13  Prior to enrollment and during the conditional enrollment
14  period in the medical assistance program, all vendors shall be
15  subject to enhanced oversight, screening, and review based on
16  the risk of fraud, waste, and abuse that is posed by the
17  category of risk of the vendor. The Illinois Department shall
18  establish the procedures for oversight, screening, and review,
19  which may include, but need not be limited to: criminal and
20  financial background checks; fingerprinting; license,
21  certification, and authorization verifications; unscheduled or
22  unannounced site visits; database checks; prepayment audit
23  reviews; audits; payment caps; payment suspensions; and other
24  screening as required by federal or State law.
25  The Department shall define or specify the following: (i)
26  by provider notice, the "category of risk of the vendor" for

 

 

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1  each type of vendor, which shall take into account the level of
2  screening applicable to a particular category of vendor under
3  federal law and regulations; (ii) by rule or provider notice,
4  the maximum length of the conditional enrollment period for
5  each category of risk of the vendor; and (iii) by rule, the
6  hearing rights, if any, afforded to a vendor in each category
7  of risk of the vendor that is terminated or disenrolled during
8  the conditional enrollment period.
9  To be eligible for payment consideration, a vendor's
10  payment claim or bill, either as an initial claim or as a
11  resubmitted claim following prior rejection, must be received
12  by the Illinois Department, or its fiscal intermediary, no
13  later than 180 days after the latest date on the claim on which
14  medical goods or services were provided, with the following
15  exceptions:
16  (1) In the case of a provider whose enrollment is in
17  process by the Illinois Department, the 180-day period
18  shall not begin until the date on the written notice from
19  the Illinois Department that the provider enrollment is
20  complete.
21  (2) In the case of errors attributable to the Illinois
22  Department or any of its claims processing intermediaries
23  which result in an inability to receive, process, or
24  adjudicate a claim, the 180-day period shall not begin
25  until the provider has been notified of the error.
26  (3) In the case of a provider for whom the Illinois

 

 

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1  Department initiates the monthly billing process.
2  (4) In the case of a provider operated by a unit of
3  local government with a population exceeding 3,000,000
4  when local government funds finance federal participation
5  for claims payments.
6  For claims for services rendered during a period for which
7  a recipient received retroactive eligibility, claims must be
8  filed within 180 days after the Department determines the
9  applicant is eligible. For claims for which the Illinois
10  Department is not the primary payer, claims must be submitted
11  to the Illinois Department within 180 days after the final
12  adjudication by the primary payer.
13  In the case of long term care facilities, within 120
14  calendar days of receipt by the facility of required
15  prescreening information, new admissions with associated
16  admission documents shall be submitted through the Medical
17  Electronic Data Interchange (MEDI) or the Recipient
18  Eligibility Verification (REV) System or shall be submitted
19  directly to the Department of Human Services using required
20  admission forms. Effective September 1, 2014, admission
21  documents, including all prescreening information, must be
22  submitted through MEDI or REV. Confirmation numbers assigned
23  to an accepted transaction shall be retained by a facility to
24  verify timely submittal. Once an admission transaction has
25  been completed, all resubmitted claims following prior
26  rejection are subject to receipt no later than 180 days after

 

 

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1  the admission transaction has been completed.
2  Claims that are not submitted and received in compliance
3  with the foregoing requirements shall not be eligible for
4  payment under the medical assistance program, and the State
5  shall have no liability for payment of those claims.
6  To the extent consistent with applicable information and
7  privacy, security, and disclosure laws, State and federal
8  agencies and departments shall provide the Illinois Department
9  access to confidential and other information and data
10  necessary to perform eligibility and payment verifications and
11  other Illinois Department functions. This includes, but is not
12  limited to: information pertaining to licensure;
13  certification; earnings; immigration status; citizenship; wage
14  reporting; unearned and earned income; pension income;
15  employment; supplemental security income; social security
16  numbers; National Provider Identifier (NPI) numbers; the
17  National Practitioner Data Bank (NPDB); program and agency
18  exclusions; taxpayer identification numbers; tax delinquency;
19  corporate information; and death records.
20  The Illinois Department shall enter into agreements with
21  State agencies and departments, and is authorized to enter
22  into agreements with federal agencies and departments, under
23  which such agencies and departments shall share data necessary
24  for medical assistance program integrity functions and
25  oversight. The Illinois Department shall develop, in
26  cooperation with other State departments and agencies, and in

 

 

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1  compliance with applicable federal laws and regulations,
2  appropriate and effective methods to share such data. At a
3  minimum, and to the extent necessary to provide data sharing,
4  the Illinois Department shall enter into agreements with State
5  agencies and departments, and is authorized to enter into
6  agreements with federal agencies and departments, including,
7  but not limited to: the Secretary of State; the Department of
8  Revenue; the Department of Public Health; the Department of
9  Human Services; and the Department of Financial and
10  Professional Regulation.
11  Beginning in fiscal year 2013, the Illinois Department
12  shall set forth a request for information to identify the
13  benefits of a pre-payment, post-adjudication, and post-edit
14  claims system with the goals of streamlining claims processing
15  and provider reimbursement, reducing the number of pending or
16  rejected claims, and helping to ensure a more transparent
17  adjudication process through the utilization of: (i) provider
18  data verification and provider screening technology; and (ii)
19  clinical code editing; and (iii) pre-pay, pre-adjudicated, or
20  post-adjudicated predictive modeling with an integrated case
21  management system with link analysis. Such a request for
22  information shall not be considered as a request for proposal
23  or as an obligation on the part of the Illinois Department to
24  take any action or acquire any products or services.
25  The Illinois Department shall establish policies,
26  procedures, standards and criteria by rule for the

 

 

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1  acquisition, repair and replacement of orthotic and prosthetic
2  devices and durable medical equipment. Such rules shall
3  provide, but not be limited to, the following services: (1)
4  immediate repair or replacement of such devices by recipients;
5  and (2) rental, lease, purchase or lease-purchase of durable
6  medical equipment in a cost-effective manner, taking into
7  consideration the recipient's medical prognosis, the extent of
8  the recipient's needs, and the requirements and costs for
9  maintaining such equipment. Subject to prior approval, such
10  rules shall enable a recipient to temporarily acquire and use
11  alternative or substitute devices or equipment pending repairs
12  or replacements of any device or equipment previously
13  authorized for such recipient by the Department.
14  Notwithstanding any provision of Section 5-5f to the contrary,
15  the Department may, by rule, exempt certain replacement
16  wheelchair parts from prior approval and, for wheelchairs,
17  wheelchair parts, wheelchair accessories, and related seating
18  and positioning items, determine the wholesale price by
19  methods other than actual acquisition costs.
20  The Department shall require, by rule, all providers of
21  durable medical equipment to be accredited by an accreditation
22  organization approved by the federal Centers for Medicare and
23  Medicaid Services and recognized by the Department in order to
24  bill the Department for providing durable medical equipment to
25  recipients. No later than 15 months after the effective date
26  of the rule adopted pursuant to this paragraph, all providers

 

 

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1  must meet the accreditation requirement.
2  In order to promote environmental responsibility, meet the
3  needs of recipients and enrollees, and achieve significant
4  cost savings, the Department, or a managed care organization
5  under contract with the Department, may provide recipients or
6  managed care enrollees who have a prescription or Certificate
7  of Medical Necessity access to refurbished durable medical
8  equipment under this Section (excluding prosthetic and
9  orthotic devices as defined in the Orthotics, Prosthetics, and
10  Pedorthics Practice Act and complex rehabilitation technology
11  products and associated services) through the State's
12  assistive technology program's reutilization program, using
13  staff with the Assistive Technology Professional (ATP)
14  Certification if the refurbished durable medical equipment:
15  (i) is available; (ii) is less expensive, including shipping
16  costs, than new durable medical equipment of the same type;
17  (iii) is able to withstand at least 3 years of use; (iv) is
18  cleaned, disinfected, sterilized, and safe in accordance with
19  federal Food and Drug Administration regulations and guidance
20  governing the reprocessing of medical devices in health care
21  settings; and (v) equally meets the needs of the recipient or
22  enrollee. The reutilization program shall confirm that the
23  recipient or enrollee is not already in receipt of the same or
24  similar equipment from another service provider, and that the
25  refurbished durable medical equipment equally meets the needs
26  of the recipient or enrollee. Nothing in this paragraph shall

 

 

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1  be construed to limit recipient or enrollee choice to obtain
2  new durable medical equipment or place any additional prior
3  authorization conditions on enrollees of managed care
4  organizations.
5  The Department shall execute, relative to the nursing home
6  prescreening project, written inter-agency agreements with the
7  Department of Human Services and the Department on Aging, to
8  effect the following: (i) intake procedures and common
9  eligibility criteria for those persons who are receiving
10  non-institutional services; and (ii) the establishment and
11  development of non-institutional services in areas of the
12  State where they are not currently available or are
13  undeveloped; and (iii) notwithstanding any other provision of
14  law, subject to federal approval, on and after July 1, 2012, an
15  increase in the determination of need (DON) scores from 29 to
16  37 for applicants for institutional and home and
17  community-based long term care; if and only if federal
18  approval is not granted, the Department may, in conjunction
19  with other affected agencies, implement utilization controls
20  or changes in benefit packages to effectuate a similar savings
21  amount for this population; and (iv) no later than July 1,
22  2013, minimum level of care eligibility criteria for
23  institutional and home and community-based long term care; and
24  (v) no later than October 1, 2013, establish procedures to
25  permit long term care providers access to eligibility scores
26  for individuals with an admission date who are seeking or

 

 

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1  receiving services from the long term care provider. In order
2  to select the minimum level of care eligibility criteria, the
3  Governor shall establish a workgroup that includes affected
4  agency representatives and stakeholders representing the
5  institutional and home and community-based long term care
6  interests. This Section shall not restrict the Department from
7  implementing lower level of care eligibility criteria for
8  community-based services in circumstances where federal
9  approval has been granted.
10  The Illinois Department shall develop and operate, in
11  cooperation with other State Departments and agencies and in
12  compliance with applicable federal laws and regulations,
13  appropriate and effective systems of health care evaluation
14  and programs for monitoring of utilization of health care
15  services and facilities, as it affects persons eligible for
16  medical assistance under this Code.
17  The Illinois Department shall report annually to the
18  General Assembly, no later than the second Friday in April of
19  1979 and each year thereafter, in regard to:
20  (a) actual statistics and trends in utilization of
21  medical services by public aid recipients;
22  (b) actual statistics and trends in the provision of
23  the various medical services by medical vendors;
24  (c) current rate structures and proposed changes in
25  those rate structures for the various medical vendors; and
26  (d) efforts at utilization review and control by the

 

 

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1  Illinois Department.
2  The period covered by each report shall be the 3 years
3  ending on the June 30 prior to the report. The report shall
4  include suggested legislation for consideration by the General
5  Assembly. The requirement for reporting to the General
6  Assembly shall be satisfied by filing copies of the report as
7  required by Section 3.1 of the General Assembly Organization
8  Act, and filing such additional copies with the State
9  Government Report Distribution Center for the General Assembly
10  as is required under paragraph (t) of Section 7 of the State
11  Library Act.
12  Rulemaking authority to implement Public Act 95-1045, if
13  any, is conditioned on the rules being adopted in accordance
14  with all provisions of the Illinois Administrative Procedure
15  Act and all rules and procedures of the Joint Committee on
16  Administrative Rules; any purported rule not so adopted, for
17  whatever reason, is unauthorized.
18  On and after July 1, 2012, the Department shall reduce any
19  rate of reimbursement for services or other payments or alter
20  any methodologies authorized by this Code to reduce any rate
21  of reimbursement for services or other payments in accordance
22  with Section 5-5e.
23  Because kidney transplantation can be an appropriate,
24  cost-effective alternative to renal dialysis when medically
25  necessary and notwithstanding the provisions of Section 1-11
26  of this Code, beginning October 1, 2014, the Department shall

 

 

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1  cover kidney transplantation for noncitizens with end-stage
2  renal disease who are not eligible for comprehensive medical
3  benefits, who meet the residency requirements of Section 5-3
4  of this Code, and who would otherwise meet the financial
5  requirements of the appropriate class of eligible persons
6  under Section 5-2 of this Code. To qualify for coverage of
7  kidney transplantation, such person must be receiving
8  emergency renal dialysis services covered by the Department.
9  Providers under this Section shall be prior approved and
10  certified by the Department to perform kidney transplantation
11  and the services under this Section shall be limited to
12  services associated with kidney transplantation.
13  Notwithstanding any other provision of this Code to the
14  contrary, on or after July 1, 2015, all FDA-approved FDA
15  approved forms of medication assisted treatment prescribed for
16  the treatment of alcohol dependence or treatment of opioid
17  dependence shall be covered under both fee-for-service and
18  managed care medical assistance programs for persons who are
19  otherwise eligible for medical assistance under this Article
20  and shall not be subject to any (1) utilization control, other
21  than those established under the American Society of Addiction
22  Medicine patient placement criteria, (2) prior authorization
23  mandate, (3) lifetime restriction limit mandate, or (4)
24  limitations on dosage.
25  On or after July 1, 2015, opioid antagonists prescribed
26  for the treatment of an opioid overdose, including the

 

 

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1  medication product, administration devices, and any pharmacy
2  fees or hospital fees related to the dispensing, distribution,
3  and administration of the opioid antagonist, shall be covered
4  under the medical assistance program for persons who are
5  otherwise eligible for medical assistance under this Article.
6  As used in this Section, "opioid antagonist" means a drug that
7  binds to opioid receptors and blocks or inhibits the effect of
8  opioids acting on those receptors, including, but not limited
9  to, naloxone hydrochloride or any other similarly acting drug
10  approved by the U.S. Food and Drug Administration. The
11  Department shall not impose a copayment on the coverage
12  provided for naloxone hydrochloride under the medical
13  assistance program.
14  Upon federal approval, the Department shall provide
15  coverage and reimbursement for all drugs that are approved for
16  marketing by the federal Food and Drug Administration and that
17  are recommended by the federal Public Health Service or the
18  United States Centers for Disease Control and Prevention for
19  pre-exposure prophylaxis and related pre-exposure prophylaxis
20  services, including, but not limited to, HIV and sexually
21  transmitted infection screening, treatment for sexually
22  transmitted infections, medical monitoring, assorted labs, and
23  counseling to reduce the likelihood of HIV infection among
24  individuals who are not infected with HIV but who are at high
25  risk of HIV infection.
26  A federally qualified health center, as defined in Section

 

 

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1  1905(l)(2)(B) of the federal Social Security Act, shall be
2  reimbursed by the Department in accordance with the federally
3  qualified health center's encounter rate for services provided
4  to medical assistance recipients that are performed by a
5  dental hygienist, as defined under the Illinois Dental
6  Practice Act, working under the general supervision of a
7  dentist and employed by a federally qualified health center.
8  Within 90 days after October 8, 2021 (the effective date
9  of Public Act 102-665), the Department shall seek federal
10  approval of a State Plan amendment to expand coverage for
11  family planning services that includes presumptive eligibility
12  to individuals whose income is at or below 208% of the federal
13  poverty level. Coverage under this Section shall be effective
14  beginning no later than December 1, 2022.
15  Subject to approval by the federal Centers for Medicare
16  and Medicaid Services of a Title XIX State Plan amendment
17  electing the Program of All-Inclusive Care for the Elderly
18  (PACE) as a State Medicaid option, as provided for by Subtitle
19  I (commencing with Section 4801) of Title IV of the Balanced
20  Budget Act of 1997 (Public Law 105-33) and Part 460
21  (commencing with Section 460.2) of Subchapter E of Title 42 of
22  the Code of Federal Regulations, PACE program services shall
23  become a covered benefit of the medical assistance program,
24  subject to criteria established in accordance with all
25  applicable laws.
26  Notwithstanding any other provision of this Code,

 

 

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1  community-based pediatric palliative care from a trained
2  interdisciplinary team shall be covered under the medical
3  assistance program as provided in Section 15 of the Pediatric
4  Palliative Care Act.
5  Notwithstanding any other provision of this Code, within
6  12 months after June 2, 2022 (the effective date of Public Act
7  102-1037) and subject to federal approval, acupuncture
8  services performed by an acupuncturist licensed under the
9  Acupuncture Practice Act who is acting within the scope of his
10  or her license shall be covered under the medical assistance
11  program. The Department shall apply for any federal waiver or
12  State Plan amendment, if required, to implement this
13  paragraph. The Department may adopt any rules, including
14  standards and criteria, necessary to implement this paragraph.
15  Notwithstanding any other provision of this Code, the
16  medical assistance program shall, subject to federal approval,
17  reimburse hospitals for costs associated with a newborn
18  screening test for the presence of metachromatic
19  leukodystrophy, as required under the Newborn Metabolic
20  Screening Act, at a rate not less than the fee charged by the
21  Department of Public Health. Notwithstanding any other
22  provision of this Code, the medical assistance program shall,
23  subject to appropriation and federal approval, also reimburse
24  hospitals for costs associated with all newborn screening
25  tests added on and after August 9, 2024 (the effective date of
26  Public Act 103-909) this amendatory Act of the 103rd General

 

 

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1  Assembly to the Newborn Metabolic Screening Act and required
2  to be performed under that Act at a rate not less than the fee
3  charged by the Department of Public Health. The Department
4  shall seek federal approval before the implementation of the
5  newborn screening test fees by the Department of Public
6  Health.
7  Notwithstanding any other provision of this Code,
8  beginning on January 1, 2024, subject to federal approval,
9  cognitive assessment and care planning services provided to a
10  person who experiences signs or symptoms of cognitive
11  impairment, as defined by the Diagnostic and Statistical
12  Manual of Mental Disorders, Fifth Edition, shall be covered
13  under the medical assistance program for persons who are
14  otherwise eligible for medical assistance under this Article.
15  Notwithstanding any other provision of this Code,
16  medically necessary reconstructive services that are intended
17  to restore physical appearance shall be covered under the
18  medical assistance program for persons who are otherwise
19  eligible for medical assistance under this Article. As used in
20  this paragraph, "reconstructive services" means treatments
21  performed on structures of the body damaged by trauma to
22  restore physical appearance.
23  No later than July 1, 2025, over-the-counter choline
24  dietary supplements for pregnant persons shall be covered
25  under the medical assistance program.
26  (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;

 

 

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1  102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2  55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
3  eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
4  102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5  5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
6  102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
7  1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
8  103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
9  1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
10  Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
11  103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
12  10-10-24.)
13  (Text of Section after amendment by P.A. 103-808)
14  Sec. 5-5. Medical services.  The Illinois Department, by
15  rule, shall determine the quantity and quality of and the rate
16  of reimbursement for the medical assistance for which payment
17  will be authorized, and the medical services to be provided,
18  which may include all or part of the following: (1) inpatient
19  hospital services; (2) outpatient hospital services; (3) other
20  laboratory and X-ray services; (4) skilled nursing home
21  services; (5) physicians' services whether furnished in the
22  office, the patient's home, a hospital, a skilled nursing
23  home, or elsewhere; (6) medical care, or any other type of
24  remedial care furnished by licensed practitioners; (7) home
25  health care services; (8) private duty nursing service; (9)

 

 

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1  clinic services; (10) dental services, including prevention
2  and treatment of periodontal disease and dental caries disease
3  for pregnant individuals, provided by an individual licensed
4  to practice dentistry or dental surgery; for purposes of this
5  item (10), "dental services" means diagnostic, preventive, or
6  corrective procedures provided by or under the supervision of
7  a dentist in the practice of his or her profession; (11)
8  physical therapy and related services; (12) prescribed drugs,
9  dentures, and prosthetic devices; and eyeglasses prescribed by
10  a physician skilled in the diseases of the eye, or by an
11  optometrist, whichever the person may select; (13) other
12  diagnostic, screening, preventive, and rehabilitative
13  services, including to ensure that the individual's need for
14  intervention or treatment of mental disorders or substance use
15  disorders or co-occurring mental health and substance use
16  disorders is determined using a uniform screening, assessment,
17  and evaluation process inclusive of criteria, for children and
18  adults; for purposes of this item (13), a uniform screening,
19  assessment, and evaluation process refers to a process that
20  includes an appropriate evaluation and, as warranted, a
21  referral; "uniform" does not mean the use of a singular
22  instrument, tool, or process that all must utilize; (14)
23  transportation and such other expenses as may be necessary;
24  (15) medical treatment of sexual assault survivors, as defined
25  in Section 1a of the Sexual Assault Survivors Emergency
26  Treatment Act, for injuries sustained as a result of the

 

 

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1  sexual assault, including examinations and laboratory tests to
2  discover evidence which may be used in criminal proceedings
3  arising from the sexual assault; (16) the diagnosis and
4  treatment of sickle cell anemia; (16.5) services performed by
5  a chiropractic physician licensed under the Medical Practice
6  Act of 1987 and acting within the scope of his or her license,
7  including, but not limited to, chiropractic manipulative
8  treatment; and (17) any other medical care, and any other type
9  of remedial care recognized under the laws of this State. The
10  term "any other type of remedial care" shall include nursing
11  care and nursing home service for persons who rely on
12  treatment by spiritual means alone through prayer for healing.
13  Notwithstanding any other provision of this Section, a
14  comprehensive tobacco use cessation program that includes
15  purchasing prescription drugs or prescription medical devices
16  approved by the Food and Drug Administration shall be covered
17  under the medical assistance program under this Article for
18  persons who are otherwise eligible for assistance under this
19  Article.
20  Notwithstanding any other provision of this Code,
21  reproductive health care that is otherwise legal in Illinois
22  shall be covered under the medical assistance program for
23  persons who are otherwise eligible for medical assistance
24  under this Article.
25  Notwithstanding any other provision of this Section, all
26  tobacco cessation medications approved by the United States

 

 

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1  Food and Drug Administration and all individual and group
2  tobacco cessation counseling services and telephone-based
3  counseling services and tobacco cessation medications provided
4  through the Illinois Tobacco Quitline shall be covered under
5  the medical assistance program for persons who are otherwise
6  eligible for assistance under this Article. The Department
7  shall comply with all federal requirements necessary to obtain
8  federal financial participation, as specified in 42 CFR
9  433.15(b)(7), for telephone-based counseling services provided
10  through the Illinois Tobacco Quitline, including, but not
11  limited to: (i) entering into a memorandum of understanding or
12  interagency agreement with the Department of Public Health, as
13  administrator of the Illinois Tobacco Quitline; and (ii)
14  developing a cost allocation plan for Medicaid-allowable
15  Illinois Tobacco Quitline services in accordance with 45 CFR
16  95.507. The Department shall submit the memorandum of
17  understanding or interagency agreement, the cost allocation
18  plan, and all other necessary documentation to the Centers for
19  Medicare and Medicaid Services for review and approval.
20  Coverage under this paragraph shall be contingent upon federal
21  approval.
22  Notwithstanding any other provision of this Code, the
23  Illinois Department may not require, as a condition of payment
24  for any laboratory test authorized under this Article, that a
25  physician's handwritten signature appear on the laboratory
26  test order form. The Illinois Department may, however, impose

 

 

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1  other appropriate requirements regarding laboratory test order
2  documentation.
3  Upon receipt of federal approval of an amendment to the
4  Illinois Title XIX State Plan for this purpose, the Department
5  shall authorize the Chicago Public Schools (CPS) to procure a
6  vendor or vendors to manufacture eyeglasses for individuals
7  enrolled in a school within the CPS system. CPS shall ensure
8  that its vendor or vendors are enrolled as providers in the
9  medical assistance program and in any capitated Medicaid
10  managed care entity (MCE) serving individuals enrolled in a
11  school within the CPS system. Under any contract procured
12  under this provision, the vendor or vendors must serve only
13  individuals enrolled in a school within the CPS system. Claims
14  for services provided by CPS's vendor or vendors to recipients
15  of benefits in the medical assistance program under this Code,
16  the Children's Health Insurance Program, or the Covering ALL
17  KIDS Health Insurance Program shall be submitted to the
18  Department or the MCE in which the individual is enrolled for
19  payment and shall be reimbursed at the Department's or the
20  MCE's established rates or rate methodologies for eyeglasses.
21  On and after July 1, 2012, the Department of Healthcare
22  and Family Services may provide the following services to
23  persons eligible for assistance under this Article who are
24  participating in education, training or employment programs
25  operated by the Department of Human Services as successor to
26  the Department of Public Aid:

 

 

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1  (1) dental services provided by or under the
2  supervision of a dentist; and
3  (2) eyeglasses prescribed by a physician skilled in
4  the diseases of the eye, or by an optometrist, whichever
5  the person may select.
6  On and after July 1, 2018, the Department of Healthcare
7  and Family Services shall provide dental services to any adult
8  who is otherwise eligible for assistance under the medical
9  assistance program. As used in this paragraph, "dental
10  services" means diagnostic, preventative, restorative, or
11  corrective procedures, including procedures and services for
12  the prevention and treatment of periodontal disease and dental
13  caries disease, provided by an individual who is licensed to
14  practice dentistry or dental surgery or who is under the
15  supervision of a dentist in the practice of his or her
16  profession.
17  On and after July 1, 2018, targeted dental services, as
18  set forth in Exhibit D of the Consent Decree entered by the
19  United States District Court for the Northern District of
20  Illinois, Eastern Division, in the matter of Memisovski v.
21  Maram, Case No. 92 C 1982, that are provided to adults under
22  the medical assistance program shall be established at no less
23  than the rates set forth in the "New Rate" column in Exhibit D
24  of the Consent Decree for targeted dental services that are
25  provided to persons under the age of 18 under the medical
26  assistance program.

 

 

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1  Subject to federal approval, on and after January 1, 2025,
2  the rates paid for sedation evaluation and the provision of
3  deep sedation and intravenous sedation for the purpose of
4  dental services shall be increased by 33% above the rates in
5  effect on December 31, 2024. The rates paid for nitrous oxide
6  sedation shall not be impacted by this paragraph and shall
7  remain the same as the rates in effect on December 31, 2024.
8  Notwithstanding any other provision of this Code and
9  subject to federal approval, the Department may adopt rules to
10  allow a dentist who is volunteering his or her service at no
11  cost to render dental services through an enrolled
12  not-for-profit health clinic without the dentist personally
13  enrolling as a participating provider in the medical
14  assistance program. A not-for-profit health clinic shall
15  include a public health clinic or Federally Qualified Health
16  Center or other enrolled provider, as determined by the
17  Department, through which dental services covered under this
18  Section are performed. The Department shall establish a
19  process for payment of claims for reimbursement for covered
20  dental services rendered under this provision.
21  Subject to appropriation and to federal approval, the
22  Department shall file administrative rules updating the
23  Handicapping Labio-Lingual Deviation orthodontic scoring tool
24  by January 1, 2025, or as soon as practicable.
25  On and after January 1, 2022, the Department of Healthcare
26  and Family Services shall administer and regulate a

 

 

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1  school-based dental program that allows for the out-of-office
2  delivery of preventative dental services in a school setting
3  to children under 19 years of age. The Department shall
4  establish, by rule, guidelines for participation by providers
5  and set requirements for follow-up referral care based on the
6  requirements established in the Dental Office Reference Manual
7  published by the Department that establishes the requirements
8  for dentists participating in the All Kids Dental School
9  Program. Every effort shall be made by the Department when
10  developing the program requirements to consider the different
11  geographic differences of both urban and rural areas of the
12  State for initial treatment and necessary follow-up care. No
13  provider shall be charged a fee by any unit of local government
14  to participate in the school-based dental program administered
15  by the Department. Nothing in this paragraph shall be
16  construed to limit or preempt a home rule unit's or school
17  district's authority to establish, change, or administer a
18  school-based dental program in addition to, or independent of,
19  the school-based dental program administered by the
20  Department.
21  The Illinois Department, by rule, may distinguish and
22  classify the medical services to be provided only in
23  accordance with the classes of persons designated in Section
24  5-2.
25  The Department of Healthcare and Family Services must
26  provide coverage and reimbursement for amino acid-based

 

 

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

 

 

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1  determined by a physician licensed to practice medicine in
2  all of its branches.
3  (F) A diagnostic mammogram when medically necessary,
4  as determined by a physician licensed to practice medicine
5  in all its branches, advanced practice registered nurse,
6  or physician assistant.
7  (G) Molecular breast imaging (MBI) and MRI of an
8  entire breast or breasts if a mammogram demonstrates
9  heterogeneous or dense breast tissue or when medically
10  necessary as determined by a physician licensed to
11  practice medicine in all of its branches, advanced
12  practice registered nurse, or physician assistant.
13  The Department shall not impose a deductible, coinsurance,
14  copayment, or any other cost-sharing requirement on the
15  coverage provided under this paragraph; except that this
16  sentence does not apply to coverage of diagnostic mammograms
17  to the extent such coverage would disqualify a high-deductible
18  health plan from eligibility for a health savings account
19  pursuant to Section 223 of the Internal Revenue Code (26
20  U.S.C. 223).
21  All screenings shall include a physical breast exam,
22  instruction on self-examination and information regarding the
23  frequency of self-examination and its value as a preventative
24  tool.
25  For purposes of this Section:
26  "Diagnostic mammogram" means a mammogram obtained using

 

 

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1  diagnostic mammography.
2  "Diagnostic mammography" means a method of screening that
3  is designed to evaluate an abnormality in a breast, including
4  an abnormality seen or suspected on a screening mammogram or a
5  subjective or objective abnormality otherwise detected in the
6  breast.
7  "Low-dose mammography" means the x-ray examination of the
8  breast using equipment dedicated specifically for mammography,
9  including the x-ray tube, filter, compression device, and
10  image receptor, with an average radiation exposure delivery of
11  less than one rad per breast for 2 views of an average size
12  breast. The term also includes digital mammography and
13  includes breast tomosynthesis.
14  "Breast tomosynthesis" means a radiologic procedure that
15  involves the acquisition of projection images over the
16  stationary breast to produce cross-sectional digital
17  three-dimensional images of the breast.
18  If, at any time, the Secretary of the United States
19  Department of Health and Human Services, or its successor
20  agency, promulgates rules or regulations to be published in
21  the Federal Register or publishes a comment in the Federal
22  Register or issues an opinion, guidance, or other action that
23  would require the State, pursuant to any provision of the
24  Patient Protection and Affordable Care Act (Public Law
25  111-148), including, but not limited to, 42 U.S.C.
26  18031(d)(3)(B) or any successor provision, to defray the cost

 

 

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1  of any coverage for breast tomosynthesis outlined in this
2  paragraph, then the requirement that an insurer cover breast
3  tomosynthesis is inoperative other than any such coverage
4  authorized under Section 1902 of the Social Security Act, 42
5  U.S.C. 1396a, and the State shall not assume any obligation
6  for the cost of coverage for breast tomosynthesis set forth in
7  this paragraph.
8  On and after January 1, 2016, the Department shall ensure
9  that all networks of care for adult clients of the Department
10  include access to at least one breast imaging Center of
11  Imaging Excellence as certified by the American College of
12  Radiology.
13  On and after January 1, 2012, providers participating in a
14  quality improvement program approved by the Department shall
15  be reimbursed for screening and diagnostic mammography at the
16  same rate as the Medicare program's rates, including the
17  increased reimbursement for digital mammography and, after
18  January 1, 2023 (the effective date of Public Act 102-1018),
19  breast tomosynthesis.
20  The Department shall convene an expert panel including
21  representatives of hospitals, free-standing mammography
22  facilities, and doctors, including radiologists, to establish
23  quality standards for mammography.
24  On and after January 1, 2017, providers participating in a
25  breast cancer treatment quality improvement program approved
26  by the Department shall be reimbursed for breast cancer

 

 

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1  treatment at a rate that is no lower than 95% of the Medicare
2  program's rates for the data elements included in the breast
3  cancer treatment quality program.
4  The Department shall convene an expert panel, including
5  representatives of hospitals, free-standing breast cancer
6  treatment centers, breast cancer quality organizations, and
7  doctors, including radiologists that are trained in all forms
8  of FDA-approved FDA approved breast imaging technologies,
9  breast surgeons, reconstructive breast surgeons, oncologists,
10  and primary care providers to establish quality standards for
11  breast cancer treatment.
12  Subject to federal approval, the Department shall
13  establish a rate methodology for mammography at federally
14  qualified health centers and other encounter-rate clinics.
15  These clinics or centers may also collaborate with other
16  hospital-based mammography facilities. By January 1, 2016, the
17  Department shall report to the General Assembly on the status
18  of the provision set forth in this paragraph.
19  The Department shall establish a methodology to remind
20  individuals who are age-appropriate for screening mammography,
21  but who have not received a mammogram within the previous 18
22  months, of the importance and benefit of screening
23  mammography. The Department shall work with experts in breast
24  cancer outreach and patient navigation to optimize these
25  reminders and shall establish a methodology for evaluating
26  their effectiveness and modifying the methodology based on the

 

 

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1  evaluation.
2  The Department shall establish a performance goal for
3  primary care providers with respect to their female patients
4  over age 40 receiving an annual mammogram. This performance
5  goal shall be used to provide additional reimbursement in the
6  form of a quality performance bonus to primary care providers
7  who meet that goal.
8  The Department shall devise a means of case-managing or
9  patient navigation for beneficiaries diagnosed with breast
10  cancer. This program shall initially operate as a pilot
11  program in areas of the State with the highest incidence of
12  mortality related to breast cancer. At least one pilot program
13  site shall be in the metropolitan Chicago area and at least one
14  site shall be outside the metropolitan Chicago area. On or
15  after July 1, 2016, the pilot program shall be expanded to
16  include one site in western Illinois, one site in southern
17  Illinois, one site in central Illinois, and 4 sites within
18  metropolitan Chicago. An evaluation of the pilot program shall
19  be carried out measuring health outcomes and cost of care for
20  those served by the pilot program compared to similarly
21  situated patients who are not served by the pilot program.
22  The Department shall require all networks of care to
23  develop a means either internally or by contract with experts
24  in navigation and community outreach to navigate cancer
25  patients to comprehensive care in a timely fashion. The
26  Department shall require all networks of care to include

 

 

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1  access for patients diagnosed with cancer to at least one
2  academic commission on cancer-accredited cancer program as an
3  in-network covered benefit.
4  The Department shall provide coverage and reimbursement
5  for a human papillomavirus (HPV) vaccine that is approved for
6  marketing by the federal Food and Drug Administration for all
7  persons between the ages of 9 and 45. Subject to federal
8  approval, the Department shall provide coverage and
9  reimbursement for a human papillomavirus (HPV) vaccine for
10  persons of the age of 46 and above who have been diagnosed with
11  cervical dysplasia with a high risk of recurrence or
12  progression. The Department shall disallow any
13  preauthorization requirements for the administration of the
14  human papillomavirus (HPV) vaccine.
15  On or after July 1, 2022, individuals who are otherwise
16  eligible for medical assistance under this Article shall
17  receive coverage for perinatal depression screenings for the
18  12-month period beginning on the last day of their pregnancy.
19  Medical assistance coverage under this paragraph shall be
20  conditioned on the use of a screening instrument approved by
21  the Department.
22  Any medical or health care provider shall immediately
23  recommend, to any pregnant individual who is being provided
24  prenatal services and is suspected of having a substance use
25  disorder as defined in the Substance Use Disorder Act,
26  referral to a local substance use disorder treatment program

 

 

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1  licensed by the Department of Human Services or to a licensed
2  hospital which provides substance abuse treatment services.
3  The Department of Healthcare and Family Services shall assure
4  coverage for the cost of treatment of the drug abuse or
5  addiction for pregnant recipients in accordance with the
6  Illinois Medicaid Program in conjunction with the Department
7  of Human Services.
8  All medical providers providing medical assistance to
9  pregnant individuals under this Code shall receive information
10  from the Department on the availability of services under any
11  program providing case management services for addicted
12  individuals, including information on appropriate referrals
13  for other social services that may be needed by addicted
14  individuals in addition to treatment for addiction.
15  The Illinois Department, in cooperation with the
16  Departments of Human Services (as successor to the Department
17  of Alcoholism and Substance Abuse) and Public Health, through
18  a public awareness campaign, may provide information
19  concerning treatment for alcoholism and drug abuse and
20  addiction, prenatal health care, and other pertinent programs
21  directed at reducing the number of drug-affected infants born
22  to recipients of medical assistance.
23  Neither the Department of Healthcare and Family Services
24  nor the Department of Human Services shall sanction the
25  recipient solely on the basis of the recipient's substance
26  abuse.

 

 

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1  The Illinois Department shall establish such regulations
2  governing the dispensing of health services under this Article
3  as it shall deem appropriate. The Department should seek the
4  advice of formal professional advisory committees appointed by
5  the Director of the Illinois Department for the purpose of
6  providing regular advice on policy and administrative matters,
7  information dissemination and educational activities for
8  medical and health care providers, and consistency in
9  procedures to the Illinois Department.
10  The Illinois Department may develop and contract with
11  Partnerships of medical providers to arrange medical services
12  for persons eligible under Section 5-2 of this Code.
13  Implementation of this Section may be by demonstration
14  projects in certain geographic areas. The Partnership shall be
15  represented by a sponsor organization. The Department, by
16  rule, shall develop qualifications for sponsors of
17  Partnerships. Nothing in this Section shall be construed to
18  require that the sponsor organization be a medical
19  organization.
20  The sponsor must negotiate formal written contracts with
21  medical providers for physician services, inpatient and
22  outpatient hospital care, home health services, treatment for
23  alcoholism and substance abuse, and other services determined
24  necessary by the Illinois Department by rule for delivery by
25  Partnerships. Physician services must include prenatal and
26  obstetrical care. The Illinois Department shall reimburse

 

 

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1  medical services delivered by Partnership providers to clients
2  in target areas according to provisions of this Article and
3  the Illinois Health Finance Reform Act, except that:
4  (1) Physicians participating in a Partnership and
5  providing certain services, which shall be determined by
6  the Illinois Department, to persons in areas covered by
7  the Partnership may receive an additional surcharge for
8  such services.
9  (2) The Department may elect to consider and negotiate
10  financial incentives to encourage the development of
11  Partnerships and the efficient delivery of medical care.
12  (3) Persons receiving medical services through
13  Partnerships may receive medical and case management
14  services above the level usually offered through the
15  medical assistance program.
16  Medical providers shall be required to meet certain
17  qualifications to participate in Partnerships to ensure the
18  delivery of high quality medical services. These
19  qualifications shall be determined by rule of the Illinois
20  Department and may be higher than qualifications for
21  participation in the medical assistance program. Partnership
22  sponsors may prescribe reasonable additional qualifications
23  for participation by medical providers, only with the prior
24  written approval of the Illinois Department.
25  Nothing in this Section shall limit the free choice of
26  practitioners, hospitals, and other providers of medical

 

 

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1  services by clients. In order to ensure patient freedom of
2  choice, the Illinois Department shall immediately promulgate
3  all rules and take all other necessary actions so that
4  provided services may be accessed from therapeutically
5  certified optometrists to the full extent of the Illinois
6  Optometric Practice Act of 1987 without discriminating between
7  service providers.
8  The Department shall apply for a waiver from the United
9  States Health Care Financing Administration to allow for the
10  implementation of Partnerships under this Section.
11  The Illinois Department shall require health care
12  providers to maintain records that document the medical care
13  and services provided to recipients of Medical Assistance
14  under this Article. Such records must be retained for a period
15  of not less than 6 years from the date of service or as
16  provided by applicable State law, whichever period is longer,
17  except that if an audit is initiated within the required
18  retention period then the records must be retained until the
19  audit is completed and every exception is resolved. The
20  Illinois Department shall require health care providers to
21  make available, when authorized by the patient, in writing,
22  the medical records in a timely fashion to other health care
23  providers who are treating or serving persons eligible for
24  Medical Assistance under this Article. All dispensers of
25  medical services shall be required to maintain and retain
26  business and professional records sufficient to fully and

 

 

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1  accurately document the nature, scope, details and receipt of
2  the health care provided to persons eligible for medical
3  assistance under this Code, in accordance with regulations
4  promulgated by the Illinois Department. The rules and
5  regulations shall require that proof of the receipt of
6  prescription drugs, dentures, prosthetic devices and
7  eyeglasses by eligible persons under this Section accompany
8  each claim for reimbursement submitted by the dispenser of
9  such medical services. No such claims for reimbursement shall
10  be approved for payment by the Illinois Department without
11  such proof of receipt, unless the Illinois Department shall
12  have put into effect and shall be operating a system of
13  post-payment audit and review which shall, on a sampling
14  basis, be deemed adequate by the Illinois Department to assure
15  that such drugs, dentures, prosthetic devices and eyeglasses
16  for which payment is being made are actually being received by
17  eligible recipients. Within 90 days after September 16, 1984
18  (the effective date of Public Act 83-1439), the Illinois
19  Department shall establish a current list of acquisition costs
20  for all prosthetic devices and any other items recognized as
21  medical equipment and supplies reimbursable under this Article
22  and shall update such list on a quarterly basis, except that
23  the acquisition costs of all prescription drugs shall be
24  updated no less frequently than every 30 days as required by
25  Section 5-5.12.
26  Notwithstanding any other law to the contrary, the

 

 

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1  Illinois Department shall, within 365 days after July 22, 2013
2  (the effective date of Public Act 98-104), establish
3  procedures to permit skilled care facilities licensed under
4  the Nursing Home Care Act to submit monthly billing claims for
5  reimbursement purposes. Following development of these
6  procedures, the Department shall, by July 1, 2016, test the
7  viability of the new system and implement any necessary
8  operational or structural changes to its information
9  technology platforms in order to allow for the direct
10  acceptance and payment of nursing home claims.
11  Notwithstanding any other law to the contrary, the
12  Illinois Department shall, within 365 days after August 15,
13  2014 (the effective date of Public Act 98-963), establish
14  procedures to permit ID/DD facilities licensed under the ID/DD
15  Community Care Act and MC/DD facilities licensed under the
16  MC/DD Act to submit monthly billing claims for reimbursement
17  purposes. Following development of these procedures, the
18  Department shall have an additional 365 days to test the
19  viability of the new system and to ensure that any necessary
20  operational or structural changes to its information
21  technology platforms are implemented.
22  The Illinois Department shall require all dispensers of
23  medical services, other than an individual practitioner or
24  group of practitioners, desiring to participate in the Medical
25  Assistance program established under this Article to disclose
26  all financial, beneficial, ownership, equity, surety or other

 

 

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1  interests in any and all firms, corporations, partnerships,
2  associations, business enterprises, joint ventures, agencies,
3  institutions or other legal entities providing any form of
4  health care services in this State under this Article.
5  The Illinois Department may require that all dispensers of
6  medical services desiring to participate in the medical
7  assistance program established under this Article disclose,
8  under such terms and conditions as the Illinois Department may
9  by rule establish, all inquiries from clients and attorneys
10  regarding medical bills paid by the Illinois Department, which
11  inquiries could indicate potential existence of claims or
12  liens for the Illinois Department.
13  Enrollment of a vendor shall be subject to a provisional
14  period and shall be conditional for one year. During the
15  period of conditional enrollment, the Department may terminate
16  the vendor's eligibility to participate in, or may disenroll
17  the vendor from, the medical assistance program without cause.
18  Unless otherwise specified, such termination of eligibility or
19  disenrollment is not subject to the Department's hearing
20  process. However, a disenrolled vendor may reapply without
21  penalty.
22  The Department has the discretion to limit the conditional
23  enrollment period for vendors based upon the category of risk
24  of the vendor.
25  Prior to enrollment and during the conditional enrollment
26  period in the medical assistance program, all vendors shall be

 

 

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1  subject to enhanced oversight, screening, and review based on
2  the risk of fraud, waste, and abuse that is posed by the
3  category of risk of the vendor. The Illinois Department shall
4  establish the procedures for oversight, screening, and review,
5  which may include, but need not be limited to: criminal and
6  financial background checks; fingerprinting; license,
7  certification, and authorization verifications; unscheduled or
8  unannounced site visits; database checks; prepayment audit
9  reviews; audits; payment caps; payment suspensions; and other
10  screening as required by federal or State law.
11  The Department shall define or specify the following: (i)
12  by provider notice, the "category of risk of the vendor" for
13  each type of vendor, which shall take into account the level of
14  screening applicable to a particular category of vendor under
15  federal law and regulations; (ii) by rule or provider notice,
16  the maximum length of the conditional enrollment period for
17  each category of risk of the vendor; and (iii) by rule, the
18  hearing rights, if any, afforded to a vendor in each category
19  of risk of the vendor that is terminated or disenrolled during
20  the conditional enrollment period.
21  To be eligible for payment consideration, a vendor's
22  payment claim or bill, either as an initial claim or as a
23  resubmitted claim following prior rejection, must be received
24  by the Illinois Department, or its fiscal intermediary, no
25  later than 180 days after the latest date on the claim on which
26  medical goods or services were provided, with the following

 

 

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1  exceptions:
2  (1) In the case of a provider whose enrollment is in
3  process by the Illinois Department, the 180-day period
4  shall not begin until the date on the written notice from
5  the Illinois Department that the provider enrollment is
6  complete.
7  (2) In the case of errors attributable to the Illinois
8  Department or any of its claims processing intermediaries
9  which result in an inability to receive, process, or
10  adjudicate a claim, the 180-day period shall not begin
11  until the provider has been notified of the error.
12  (3) In the case of a provider for whom the Illinois
13  Department initiates the monthly billing process.
14  (4) In the case of a provider operated by a unit of
15  local government with a population exceeding 3,000,000
16  when local government funds finance federal participation
17  for claims payments.
18  For claims for services rendered during a period for which
19  a recipient received retroactive eligibility, claims must be
20  filed within 180 days after the Department determines the
21  applicant is eligible. For claims for which the Illinois
22  Department is not the primary payer, claims must be submitted
23  to the Illinois Department within 180 days after the final
24  adjudication by the primary payer.
25  In the case of long term care facilities, within 120
26  calendar days of receipt by the facility of required

 

 

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1  prescreening information, new admissions with associated
2  admission documents shall be submitted through the Medical
3  Electronic Data Interchange (MEDI) or the Recipient
4  Eligibility Verification (REV) System or shall be submitted
5  directly to the Department of Human Services using required
6  admission forms. Effective September 1, 2014, admission
7  documents, including all prescreening information, must be
8  submitted through MEDI or REV. Confirmation numbers assigned
9  to an accepted transaction shall be retained by a facility to
10  verify timely submittal. Once an admission transaction has
11  been completed, all resubmitted claims following prior
12  rejection are subject to receipt no later than 180 days after
13  the admission transaction has been completed.
14  Claims that are not submitted and received in compliance
15  with the foregoing requirements shall not be eligible for
16  payment under the medical assistance program, and the State
17  shall have no liability for payment of those claims.
18  To the extent consistent with applicable information and
19  privacy, security, and disclosure laws, State and federal
20  agencies and departments shall provide the Illinois Department
21  access to confidential and other information and data
22  necessary to perform eligibility and payment verifications and
23  other Illinois Department functions. This includes, but is not
24  limited to: information pertaining to licensure;
25  certification; earnings; immigration status; citizenship; wage
26  reporting; unearned and earned income; pension income;

 

 

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1  employment; supplemental security income; social security
2  numbers; National Provider Identifier (NPI) numbers; the
3  National Practitioner Data Bank (NPDB); program and agency
4  exclusions; taxpayer identification numbers; tax delinquency;
5  corporate information; and death records.
6  The Illinois Department shall enter into agreements with
7  State agencies and departments, and is authorized to enter
8  into agreements with federal agencies and departments, under
9  which such agencies and departments shall share data necessary
10  for medical assistance program integrity functions and
11  oversight. The Illinois Department shall develop, in
12  cooperation with other State departments and agencies, and in
13  compliance with applicable federal laws and regulations,
14  appropriate and effective methods to share such data. At a
15  minimum, and to the extent necessary to provide data sharing,
16  the Illinois Department shall enter into agreements with State
17  agencies and departments, and is authorized to enter into
18  agreements with federal agencies and departments, including,
19  but not limited to: the Secretary of State; the Department of
20  Revenue; the Department of Public Health; the Department of
21  Human Services; and the Department of Financial and
22  Professional Regulation.
23  Beginning in fiscal year 2013, the Illinois Department
24  shall set forth a request for information to identify the
25  benefits of a pre-payment, post-adjudication, and post-edit
26  claims system with the goals of streamlining claims processing

 

 

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1  and provider reimbursement, reducing the number of pending or
2  rejected claims, and helping to ensure a more transparent
3  adjudication process through the utilization of: (i) provider
4  data verification and provider screening technology; and (ii)
5  clinical code editing; and (iii) pre-pay, pre-adjudicated, or
6  post-adjudicated predictive modeling with an integrated case
7  management system with link analysis. Such a request for
8  information shall not be considered as a request for proposal
9  or as an obligation on the part of the Illinois Department to
10  take any action or acquire any products or services.
11  The Illinois Department shall establish policies,
12  procedures, standards and criteria by rule for the
13  acquisition, repair and replacement of orthotic and prosthetic
14  devices and durable medical equipment. Such rules shall
15  provide, but not be limited to, the following services: (1)
16  immediate repair or replacement of such devices by recipients;
17  and (2) rental, lease, purchase or lease-purchase of durable
18  medical equipment in a cost-effective manner, taking into
19  consideration the recipient's medical prognosis, the extent of
20  the recipient's needs, and the requirements and costs for
21  maintaining such equipment. Subject to prior approval, such
22  rules shall enable a recipient to temporarily acquire and use
23  alternative or substitute devices or equipment pending repairs
24  or replacements of any device or equipment previously
25  authorized for such recipient by the Department.
26  Notwithstanding any provision of Section 5-5f to the contrary,

 

 

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1  the Department may, by rule, exempt certain replacement
2  wheelchair parts from prior approval and, for wheelchairs,
3  wheelchair parts, wheelchair accessories, and related seating
4  and positioning items, determine the wholesale price by
5  methods other than actual acquisition costs.
6  The Department shall require, by rule, all providers of
7  durable medical equipment to be accredited by an accreditation
8  organization approved by the federal Centers for Medicare and
9  Medicaid Services and recognized by the Department in order to
10  bill the Department for providing durable medical equipment to
11  recipients. No later than 15 months after the effective date
12  of the rule adopted pursuant to this paragraph, all providers
13  must meet the accreditation requirement.
14  In order to promote environmental responsibility, meet the
15  needs of recipients and enrollees, and achieve significant
16  cost savings, the Department, or a managed care organization
17  under contract with the Department, may provide recipients or
18  managed care enrollees who have a prescription or Certificate
19  of Medical Necessity access to refurbished durable medical
20  equipment under this Section (excluding prosthetic and
21  orthotic devices as defined in the Orthotics, Prosthetics, and
22  Pedorthics Practice Act and complex rehabilitation technology
23  products and associated services) through the State's
24  assistive technology program's reutilization program, using
25  staff with the Assistive Technology Professional (ATP)
26  Certification if the refurbished durable medical equipment:

 

 

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1  (i) is available; (ii) is less expensive, including shipping
2  costs, than new durable medical equipment of the same type;
3  (iii) is able to withstand at least 3 years of use; (iv) is
4  cleaned, disinfected, sterilized, and safe in accordance with
5  federal Food and Drug Administration regulations and guidance
6  governing the reprocessing of medical devices in health care
7  settings; and (v) equally meets the needs of the recipient or
8  enrollee. The reutilization program shall confirm that the
9  recipient or enrollee is not already in receipt of the same or
10  similar equipment from another service provider, and that the
11  refurbished durable medical equipment equally meets the needs
12  of the recipient or enrollee. Nothing in this paragraph shall
13  be construed to limit recipient or enrollee choice to obtain
14  new durable medical equipment or place any additional prior
15  authorization conditions on enrollees of managed care
16  organizations.
17  The Department shall execute, relative to the nursing home
18  prescreening project, written inter-agency agreements with the
19  Department of Human Services and the Department on Aging, to
20  effect the following: (i) intake procedures and common
21  eligibility criteria for those persons who are receiving
22  non-institutional services; and (ii) the establishment and
23  development of non-institutional services in areas of the
24  State where they are not currently available or are
25  undeveloped; and (iii) notwithstanding any other provision of
26  law, subject to federal approval, on and after July 1, 2012, an

 

 

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1  increase in the determination of need (DON) scores from 29 to
2  37 for applicants for institutional and home and
3  community-based long term care; if and only if federal
4  approval is not granted, the Department may, in conjunction
5  with other affected agencies, implement utilization controls
6  or changes in benefit packages to effectuate a similar savings
7  amount for this population; and (iv) no later than July 1,
8  2013, minimum level of care eligibility criteria for
9  institutional and home and community-based long term care; and
10  (v) no later than October 1, 2013, establish procedures to
11  permit long term care providers access to eligibility scores
12  for individuals with an admission date who are seeking or
13  receiving services from the long term care provider. In order
14  to select the minimum level of care eligibility criteria, the
15  Governor shall establish a workgroup that includes affected
16  agency representatives and stakeholders representing the
17  institutional and home and community-based long term care
18  interests. This Section shall not restrict the Department from
19  implementing lower level of care eligibility criteria for
20  community-based services in circumstances where federal
21  approval has been granted.
22  The Illinois Department shall develop and operate, in
23  cooperation with other State Departments and agencies and in
24  compliance with applicable federal laws and regulations,
25  appropriate and effective systems of health care evaluation
26  and programs for monitoring of utilization of health care

 

 

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1  services and facilities, as it affects persons eligible for
2  medical assistance under this Code.
3  The Illinois Department shall report annually to the
4  General Assembly, no later than the second Friday in April of
5  1979 and each year thereafter, in regard to:
6  (a) actual statistics and trends in utilization of
7  medical services by public aid recipients;
8  (b) actual statistics and trends in the provision of
9  the various medical services by medical vendors;
10  (c) current rate structures and proposed changes in
11  those rate structures for the various medical vendors; and
12  (d) efforts at utilization review and control by the
13  Illinois Department.
14  The period covered by each report shall be the 3 years
15  ending on the June 30 prior to the report. The report shall
16  include suggested legislation for consideration by the General
17  Assembly. The requirement for reporting to the General
18  Assembly shall be satisfied by filing copies of the report as
19  required by Section 3.1 of the General Assembly Organization
20  Act, and filing such additional copies with the State
21  Government Report Distribution Center for the General Assembly
22  as is required under paragraph (t) of Section 7 of the State
23  Library Act.
24  Rulemaking authority to implement Public Act 95-1045, if
25  any, is conditioned on the rules being adopted in accordance
26  with all provisions of the Illinois Administrative Procedure

 

 

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1  Act and all rules and procedures of the Joint Committee on
2  Administrative Rules; any purported rule not so adopted, for
3  whatever reason, is unauthorized.
4  On and after July 1, 2012, the Department shall reduce any
5  rate of reimbursement for services or other payments or alter
6  any methodologies authorized by this Code to reduce any rate
7  of reimbursement for services or other payments in accordance
8  with Section 5-5e.
9  Because kidney transplantation can be an appropriate,
10  cost-effective alternative to renal dialysis when medically
11  necessary and notwithstanding the provisions of Section 1-11
12  of this Code, beginning October 1, 2014, the Department shall
13  cover kidney transplantation for noncitizens with end-stage
14  renal disease who are not eligible for comprehensive medical
15  benefits, who meet the residency requirements of Section 5-3
16  of this Code, and who would otherwise meet the financial
17  requirements of the appropriate class of eligible persons
18  under Section 5-2 of this Code. To qualify for coverage of
19  kidney transplantation, such person must be receiving
20  emergency renal dialysis services covered by the Department.
21  Providers under this Section shall be prior approved and
22  certified by the Department to perform kidney transplantation
23  and the services under this Section shall be limited to
24  services associated with kidney transplantation.
25  Notwithstanding any other provision of this Code to the
26  contrary, on or after July 1, 2015, all FDA-approved FDA

 

 

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1  approved forms of medication assisted treatment prescribed for
2  the treatment of alcohol dependence or treatment of opioid
3  dependence shall be covered under both fee-for-service and
4  managed care medical assistance programs for persons who are
5  otherwise eligible for medical assistance under this Article
6  and shall not be subject to any (1) utilization control, other
7  than those established under the American Society of Addiction
8  Medicine patient placement criteria, (2) prior authorization
9  mandate, (3) lifetime restriction limit mandate, or (4)
10  limitations on dosage.
11  On or after July 1, 2015, opioid antagonists prescribed
12  for the treatment of an opioid overdose, including the
13  medication product, administration devices, and any pharmacy
14  fees or hospital fees related to the dispensing, distribution,
15  and administration of the opioid antagonist, shall be covered
16  under the medical assistance program for persons who are
17  otherwise eligible for medical assistance under this Article.
18  As used in this Section, "opioid antagonist" means a drug that
19  binds to opioid receptors and blocks or inhibits the effect of
20  opioids acting on those receptors, including, but not limited
21  to, naloxone hydrochloride or any other similarly acting drug
22  approved by the U.S. Food and Drug Administration. The
23  Department shall not impose a copayment on the coverage
24  provided for naloxone hydrochloride under the medical
25  assistance program.
26  Upon federal approval, the Department shall provide

 

 

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1  coverage and reimbursement for all drugs that are approved for
2  marketing by the federal Food and Drug Administration and that
3  are recommended by the federal Public Health Service or the
4  United States Centers for Disease Control and Prevention for
5  pre-exposure prophylaxis and related pre-exposure prophylaxis
6  services, including, but not limited to, HIV and sexually
7  transmitted infection screening, treatment for sexually
8  transmitted infections, medical monitoring, assorted labs, and
9  counseling to reduce the likelihood of HIV infection among
10  individuals who are not infected with HIV but who are at high
11  risk of HIV infection.
12  A federally qualified health center, as defined in Section
13  1905(l)(2)(B) of the federal Social Security Act, shall be
14  reimbursed by the Department in accordance with the federally
15  qualified health center's encounter rate for services provided
16  to medical assistance recipients that are performed by a
17  dental hygienist, as defined under the Illinois Dental
18  Practice Act, working under the general supervision of a
19  dentist and employed by a federally qualified health center.
20  Within 90 days after October 8, 2021 (the effective date
21  of Public Act 102-665), the Department shall seek federal
22  approval of a State Plan amendment to expand coverage for
23  family planning services that includes presumptive eligibility
24  to individuals whose income is at or below 208% of the federal
25  poverty level. Coverage under this Section shall be effective
26  beginning no later than December 1, 2022.

 

 

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1  Subject to approval by the federal Centers for Medicare
2  and Medicaid Services of a Title XIX State Plan amendment
3  electing the Program of All-Inclusive Care for the Elderly
4  (PACE) as a State Medicaid option, as provided for by Subtitle
5  I (commencing with Section 4801) of Title IV of the Balanced
6  Budget Act of 1997 (Public Law 105-33) and Part 460
7  (commencing with Section 460.2) of Subchapter E of Title 42 of
8  the Code of Federal Regulations, PACE program services shall
9  become a covered benefit of the medical assistance program,
10  subject to criteria established in accordance with all
11  applicable laws.
12  Notwithstanding any other provision of this Code,
13  community-based pediatric palliative care from a trained
14  interdisciplinary team shall be covered under the medical
15  assistance program as provided in Section 15 of the Pediatric
16  Palliative Care Act.
17  Notwithstanding any other provision of this Code, within
18  12 months after June 2, 2022 (the effective date of Public Act
19  102-1037) and subject to federal approval, acupuncture
20  services performed by an acupuncturist licensed under the
21  Acupuncture Practice Act who is acting within the scope of his
22  or her license shall be covered under the medical assistance
23  program. The Department shall apply for any federal waiver or
24  State Plan amendment, if required, to implement this
25  paragraph. The Department may adopt any rules, including
26  standards and criteria, necessary to implement this paragraph.

 

 

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1  Notwithstanding any other provision of this Code, the
2  medical assistance program shall, subject to federal approval,
3  reimburse hospitals for costs associated with a newborn
4  screening test for the presence of metachromatic
5  leukodystrophy, as required under the Newborn Metabolic
6  Screening Act, at a rate not less than the fee charged by the
7  Department of Public Health. Notwithstanding any other
8  provision of this Code, the medical assistance program shall,
9  subject to appropriation and federal approval, also reimburse
10  hospitals for costs associated with all newborn screening
11  tests added on and after August 9, 2024 (the effective date of
12  Public Act 103-909) this amendatory Act of the 103rd General
13  Assembly to the Newborn Metabolic Screening Act and required
14  to be performed under that Act at a rate not less than the fee
15  charged by the Department of Public Health. The Department
16  shall seek federal approval before the implementation of the
17  newborn screening test fees by the Department of Public
18  Health.
19  Notwithstanding any other provision of this Code,
20  beginning on January 1, 2024, subject to federal approval,
21  cognitive assessment and care planning services provided to a
22  person who experiences signs or symptoms of cognitive
23  impairment, as defined by the Diagnostic and Statistical
24  Manual of Mental Disorders, Fifth Edition, shall be covered
25  under the medical assistance program for persons who are
26  otherwise eligible for medical assistance under this Article.

 

 

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1  Notwithstanding any other provision of this Code,
2  medically necessary reconstructive services that are intended
3  to restore physical appearance shall be covered under the
4  medical assistance program for persons who are otherwise
5  eligible for medical assistance under this Article. As used in
6  this paragraph, "reconstructive services" means treatments
7  performed on structures of the body damaged by trauma to
8  restore physical appearance.
9  No later than July 1, 2025, over-the-counter choline
10  dietary supplements for pregnant persons shall be covered
11  under the medical assistance program.
12  (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
13  102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
14  55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
15  eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
16  102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
17  5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
18  102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
19  1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
20  103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
21  1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
22  Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
23  103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
24  8-9-24; revised 10-10-24.)
25  Section 95. No acceleration or delay. Where this Act makes

 

 

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1  changes in a statute that is represented in this Act by text
2  that is not yet or no longer in effect (for example, a Section
3  represented by multiple versions), the use of that text does
4  not accelerate or delay the taking effect of (i) the changes
5  made by this Act or (ii) provisions derived from any other
6  Public Act.

 

 

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