Illinois 2025-2026 Regular Session

Illinois House Bill HB2552 Compare Versions

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

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1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2552 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after January 1, 2026, the reimbursement rates for all dental services for children shall be increased 50% above the rates in effect on December 31, 2025. Effective January 1, 2026. LRB104 06102 KTG 16135 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2552 Introduced , by Rep. Joyce Mason 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 on and after January 1, 2026, the reimbursement rates for all dental services for children shall be increased 50% above the rates in effect on December 31, 2025. Effective January 1, 2026. LRB104 06102 KTG 16135 b LRB104 06102 KTG 16135 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2552 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5 305 ILCS 5/5-5
4	4	305 ILCS 5/5-5
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after January 1, 2026, the reimbursement rates for all dental services for children shall be increased 50% above the rates in effect on December 31, 2025. Effective January 1, 2026.
6	6	LRB104 06102 KTG 16135 b LRB104 06102 KTG 16135 b
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8	8	A BILL FOR
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10	10	HB2552 LRB104 06102 KTG 16135 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5 as follows:
16	16	6 (305 ILCS 5/5-5)
17	17	7 Sec. 5-5. Medical services. The Illinois Department, by
18	18	8 rule, shall determine the quantity and quality of and the rate
19	19	9 of reimbursement for the medical assistance for which payment
20	20	10 will be authorized, and the medical services to be provided,
21	21	11 which may include all or part of the following: (1) inpatient
22	22	12 hospital services; (2) outpatient hospital services; (3) other
23	23	13 laboratory and X-ray services; (4) skilled nursing home
24	24	14 services; (5) physicians' services whether furnished in the
25	25	15 office, the patient's home, a hospital, a skilled nursing
26	26	16 home, or elsewhere; (6) medical care, or any other type of
27	27	17 remedial care furnished by licensed practitioners; (7) home
28	28	18 health care services; (8) private duty nursing service; (9)
29	29	19 clinic services; (10) dental services, including prevention
30	30	20 and treatment of periodontal disease and dental caries disease
31	31	21 for pregnant individuals, provided by an individual licensed
32	32	22 to practice dentistry or dental surgery; for purposes of this
33	33	23 item (10), "dental services" means diagnostic, preventive, or
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37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2552 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5 305 ILCS 5/5-5
39	39	305 ILCS 5/5-5
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after January 1, 2026, the reimbursement rates for all dental services for children shall be increased 50% above the rates in effect on December 31, 2025. Effective January 1, 2026.
41	41	LRB104 06102 KTG 16135 b LRB104 06102 KTG 16135 b
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43	43	A BILL FOR
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68	68	1 corrective procedures provided by or under the supervision of
69	69	2 a dentist in the practice of his or her profession; (11)
70	70	3 physical therapy and related services; (12) prescribed drugs,
71	71	4 dentures, and prosthetic devices; and eyeglasses prescribed by
72	72	5 a physician skilled in the diseases of the eye, or by an
73	73	6 optometrist, whichever the person may select; (13) other
74	74	7 diagnostic, screening, preventive, and rehabilitative
75	75	8 services, including to ensure that the individual's need for
76	76	9 intervention or treatment of mental disorders or substance use
77	77	10 disorders or co-occurring mental health and substance use
78	78	11 disorders is determined using a uniform screening, assessment,
79	79	12 and evaluation process inclusive of criteria, for children and
80	80	13 adults; for purposes of this item (13), a uniform screening,
81	81	14 assessment, and evaluation process refers to a process that
82	82	15 includes an appropriate evaluation and, as warranted, a
83	83	16 referral; "uniform" does not mean the use of a singular
84	84	17 instrument, tool, or process that all must utilize; (14)
85	85	18 transportation and such other expenses as may be necessary;
86	86	19 (15) medical treatment of sexual assault survivors, as defined
87	87	20 in Section 1a of the Sexual Assault Survivors Emergency
88	88	21 Treatment Act, for injuries sustained as a result of the
89	89	22 sexual assault, including examinations and laboratory tests to
90	90	23 discover evidence which may be used in criminal proceedings
91	91	24 arising from the sexual assault; (16) the diagnosis and
92	92	25 treatment of sickle cell anemia; (16.5) services performed by
93	93	26 a chiropractic physician licensed under the Medical Practice
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104	104	1 Act of 1987 and acting within the scope of his or her license,
105	105	2 including, but not limited to, chiropractic manipulative
106	106	3 treatment; and (17) any other medical care, and any other type
107	107	4 of remedial care recognized under the laws of this State. The
108	108	5 term "any other type of remedial care" shall include nursing
109	109	6 care and nursing home service for persons who rely on
110	110	7 treatment by spiritual means alone through prayer for healing.
111	111	8 Notwithstanding any other provision of this Section, a
112	112	9 comprehensive tobacco use cessation program that includes
113	113	10 purchasing prescription drugs or prescription medical devices
114	114	11 approved by the Food and Drug Administration shall be covered
115	115	12 under the medical assistance program under this Article for
116	116	13 persons who are otherwise eligible for assistance under this
117	117	14 Article.
118	118	15 Notwithstanding any other provision of this Code,
119	119	16 reproductive health care that is otherwise legal in Illinois
120	120	17 shall be covered under the medical assistance program for
121	121	18 persons who are otherwise eligible for medical assistance
122	122	19 under this Article.
123	123	20 Notwithstanding any other provision of this Section, all
124	124	21 tobacco cessation medications approved by the United States
125	125	22 Food and Drug Administration and all individual and group
126	126	23 tobacco cessation counseling services and telephone-based
127	127	24 counseling services and tobacco cessation medications provided
128	128	25 through the Illinois Tobacco Quitline shall be covered under
129	129	26 the medical assistance program for persons who are otherwise
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140	140	1 eligible for assistance under this Article. The Department
141	141	2 shall comply with all federal requirements necessary to obtain
142	142	3 federal financial participation, as specified in 42 CFR
143	143	4 433.15(b)(7), for telephone-based counseling services provided
144	144	5 through the Illinois Tobacco Quitline, including, but not
145	145	6 limited to: (i) entering into a memorandum of understanding or
146	146	7 interagency agreement with the Department of Public Health, as
147	147	8 administrator of the Illinois Tobacco Quitline; and (ii)
148	148	9 developing a cost allocation plan for Medicaid-allowable
149	149	10 Illinois Tobacco Quitline services in accordance with 45 CFR
150	150	11 95.507. The Department shall submit the memorandum of
151	151	12 understanding or interagency agreement, the cost allocation
152	152	13 plan, and all other necessary documentation to the Centers for
153	153	14 Medicare and Medicaid Services for review and approval.
154	154	15 Coverage under this paragraph shall be contingent upon federal
155	155	16 approval.
156	156	17 Notwithstanding any other provision of this Code, the
157	157	18 Illinois Department may not require, as a condition of payment
158	158	19 for any laboratory test authorized under this Article, that a
159	159	20 physician's handwritten signature appear on the laboratory
160	160	21 test order form. The Illinois Department may, however, impose
161	161	22 other appropriate requirements regarding laboratory test order
162	162	23 documentation.
163	163	24 Upon receipt of federal approval of an amendment to the
164	164	25 Illinois Title XIX State Plan for this purpose, the Department
165	165	26 shall authorize the Chicago Public Schools (CPS) to procure a
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176	176	1 vendor or vendors to manufacture eyeglasses for individuals
177	177	2 enrolled in a school within the CPS system. CPS shall ensure
178	178	3 that its vendor or vendors are enrolled as providers in the
179	179	4 medical assistance program and in any capitated Medicaid
180	180	5 managed care entity (MCE) serving individuals enrolled in a
181	181	6 school within the CPS system. Under any contract procured
182	182	7 under this provision, the vendor or vendors must serve only
183	183	8 individuals enrolled in a school within the CPS system. Claims
184	184	9 for services provided by CPS's vendor or vendors to recipients
185	185	10 of benefits in the medical assistance program under this Code,
186	186	11 the Children's Health Insurance Program, or the Covering ALL
187	187	12 KIDS Health Insurance Program shall be submitted to the
188	188	13 Department or the MCE in which the individual is enrolled for
189	189	14 payment and shall be reimbursed at the Department's or the
190	190	15 MCE's established rates or rate methodologies for eyeglasses.
191	191	16 On and after July 1, 2012, the Department of Healthcare
192	192	17 and Family Services may provide the following services to
193	193	18 persons eligible for assistance under this Article who are
194	194	19 participating in education, training or employment programs
195	195	20 operated by the Department of Human Services as successor to
196	196	21 the Department of Public Aid:
197	197	22 (1) dental services provided by or under the
198	198	23 supervision of a dentist; and
199	199	24 (2) eyeglasses prescribed by a physician skilled in
200	200	25 the diseases of the eye, or by an optometrist, whichever
201	201	26 the person may select.
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212	212	1 On and after July 1, 2018, the Department of Healthcare
213	213	2 and Family Services shall provide dental services to any adult
214	214	3 who is otherwise eligible for assistance under the medical
215	215	4 assistance program. As used in this paragraph, "dental
216	216	5 services" means diagnostic, preventative, restorative, or
217	217	6 corrective procedures, including procedures and services for
218	218	7 the prevention and treatment of periodontal disease and dental
219	219	8 caries disease, provided by an individual who is licensed to
220	220	9 practice dentistry or dental surgery or who is under the
221	221	10 supervision of a dentist in the practice of his or her
222	222	11 profession.
223	223	12 On and after July 1, 2018, targeted dental services, as
224	224	13 set forth in Exhibit D of the Consent Decree entered by the
225	225	14 United States District Court for the Northern District of
226	226	15 Illinois, Eastern Division, in the matter of Memisovski v.
227	227	16 Maram, Case No. 92 C 1982, that are provided to adults under
228	228	17 the medical assistance program shall be established at no less
229	229	18 than the rates set forth in the "New Rate" column in Exhibit D
230	230	19 of the Consent Decree for targeted dental services that are
231	231	20 provided to persons under the age of 18 under the medical
232	232	21 assistance program.
233	233	22 Subject to federal approval, on and after January 1, 2025,
234	234	23 the rates paid for sedation evaluation and the provision of
235	235	24 deep sedation and intravenous sedation for the purpose of
236	236	25 dental services shall be increased by 33% above the rates in
237	237	26 effect on December 31, 2024. The rates paid for nitrous oxide
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248	248	1 sedation shall not be impacted by this paragraph and shall
249	249	2 remain the same as the rates in effect on December 31, 2024.
250	250	3 Notwithstanding any other provision of this Code and
251	251	4 subject to federal approval, the Department may adopt rules to
252	252	5 allow a dentist who is volunteering his or her service at no
253	253	6 cost to render dental services through an enrolled
254	254	7 not-for-profit health clinic without the dentist personally
255	255	8 enrolling as a participating provider in the medical
256	256	9 assistance program. A not-for-profit health clinic shall
257	257	10 include a public health clinic or Federally Qualified Health
258	258	11 Center or other enrolled provider, as determined by the
259	259	12 Department, through which dental services covered under this
260	260	13 Section are performed. The Department shall establish a
261	261	14 process for payment of claims for reimbursement for covered
262	262	15 dental services rendered under this provision.
263	263	16 Subject to appropriation and to federal approval, the
264	264	17 Department shall file administrative rules updating the
265	265	18 Handicapping Labio-Lingual Deviation orthodontic scoring tool
266	266	19 by January 1, 2025, or as soon as practicable.
267	267	20 On and after January 1, 2022, the Department of Healthcare
268	268	21 and Family Services shall administer and regulate a
269	269	22 school-based dental program that allows for the out-of-office
270	270	23 delivery of preventative dental services in a school setting
271	271	24 to children under 19 years of age. The Department shall
272	272	25 establish, by rule, guidelines for participation by providers
273	273	26 and set requirements for follow-up referral care based on the
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284	284	1 requirements established in the Dental Office Reference Manual
285	285	2 published by the Department that establishes the requirements
286	286	3 for dentists participating in the All Kids Dental School
287	287	4 Program. Every effort shall be made by the Department when
288	288	5 developing the program requirements to consider the different
289	289	6 geographic differences of both urban and rural areas of the
290	290	7 State for initial treatment and necessary follow-up care. No
291	291	8 provider shall be charged a fee by any unit of local government
292	292	9 to participate in the school-based dental program administered
293	293	10 by the Department. Nothing in this paragraph shall be
294	294	11 construed to limit or preempt a home rule unit's or school
295	295	12 district's authority to establish, change, or administer a
296	296	13 school-based dental program in addition to, or independent of,
297	297	14 the school-based dental program administered by the
298	298	15 Department.
299	299	16 On and after January 1, 2026, the reimbursement rates for
300	300	17 all dental services for children shall be increased 50% above
301	301	18 the rates in effect on December 31, 2025.
302	302	19 The Illinois Department, by rule, may distinguish and
303	303	20 classify the medical services to be provided only in
304	304	21 accordance with the classes of persons designated in Section
305	305	22 5-2.
306	306	23 The Department of Healthcare and Family Services must
307	307	24 provide coverage and reimbursement for amino acid-based
308	308	25 elemental formulas, regardless of delivery method, for the
309	309	26 diagnosis and treatment of (i) eosinophilic disorders and (ii)
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320	320	1 short bowel syndrome when the prescribing physician has issued
321	321	2 a written order stating that the amino acid-based elemental
322	322	3 formula is medically necessary.
323	323	4 The Illinois Department shall authorize the provision of,
324	324	5 and shall authorize payment for, screening by low-dose
325	325	6 mammography for the presence of occult breast cancer for
326	326	7 individuals 35 years of age or older who are eligible for
327	327	8 medical assistance under this Article, as follows:
328	328	9 (A) A baseline mammogram for individuals 35 to 39
329	329	10 years of age.
330	330	11 (B) An annual mammogram for individuals 40 years of
331	331	12 age or older.
332	332	13 (C) A mammogram at the age and intervals considered
333	333	14 medically necessary by the individual's health care
334	334	15 provider for individuals under 40 years of age and having
335	335	16 a family history of breast cancer, prior personal history
336	336	17 of breast cancer, positive genetic testing, or other risk
337	337	18 factors.
338	338	19 (D) A comprehensive ultrasound screening and MRI of an
339	339	20 entire breast or breasts if a mammogram demonstrates
340	340	21 heterogeneous or dense breast tissue or when medically
341	341	22 necessary as determined by a physician licensed to
342	342	23 practice medicine in all of its branches.
343	343	24 (E) A screening MRI when medically necessary, as
344	344	25 determined by a physician licensed to practice medicine in
345	345	26 all of its branches.
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356	356	1 (F) A diagnostic mammogram when medically necessary,
357	357	2 as determined by a physician licensed to practice medicine
358	358	3 in all its branches, advanced practice registered nurse,
359	359	4 or physician assistant.
360	360	5 (G) Molecular breast imaging (MBI) and MRI of an
361	361	6 entire breast or breasts if a mammogram demonstrates
362	362	7 heterogeneous or dense breast tissue or when medically
363	363	8 necessary as determined by a physician licensed to
364	364	9 practice medicine in all of its branches, advanced
365	365	10 practice registered nurse, or physician assistant.
366	366	11 The Department shall not impose a deductible, coinsurance,
367	367	12 copayment, or any other cost-sharing requirement on the
368	368	13 coverage provided under this paragraph; except that this
369	369	14 sentence does not apply to coverage of diagnostic mammograms
370	370	15 to the extent such coverage would disqualify a high-deductible
371	371	16 health plan from eligibility for a health savings account
372	372	17 pursuant to Section 223 of the Internal Revenue Code (26
373	373	18 U.S.C. 223).
374	374	19 All screenings shall include a physical breast exam,
375	375	20 instruction on self-examination and information regarding the
376	376	21 frequency of self-examination and its value as a preventative
377	377	22 tool.
378	378	23 For purposes of this Section:
379	379	24 "Diagnostic mammogram" means a mammogram obtained using
380	380	25 diagnostic mammography.
381	381	26 "Diagnostic mammography" means a method of screening that
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392	392	1 is designed to evaluate an abnormality in a breast, including
393	393	2 an abnormality seen or suspected on a screening mammogram or a
394	394	3 subjective or objective abnormality otherwise detected in the
395	395	4 breast.
396	396	5 "Low-dose mammography" means the x-ray examination of the
397	397	6 breast using equipment dedicated specifically for mammography,
398	398	7 including the x-ray tube, filter, compression device, and
399	399	8 image receptor, with an average radiation exposure delivery of
400	400	9 less than one rad per breast for 2 views of an average size
401	401	10 breast. The term also includes digital mammography and
402	402	11 includes breast tomosynthesis.
403	403	12 "Breast tomosynthesis" means a radiologic procedure that
404	404	13 involves the acquisition of projection images over the
405	405	14 stationary breast to produce cross-sectional digital
406	406	15 three-dimensional images of the breast.
407	407	16 If, at any time, the Secretary of the United States
408	408	17 Department of Health and Human Services, or its successor
409	409	18 agency, promulgates rules or regulations to be published in
410	410	19 the Federal Register or publishes a comment in the Federal
411	411	20 Register or issues an opinion, guidance, or other action that
412	412	21 would require the State, pursuant to any provision of the
413	413	22 Patient Protection and Affordable Care Act (Public Law
414	414	23 111-148), including, but not limited to, 42 U.S.C.
415	415	24 18031(d)(3)(B) or any successor provision, to defray the cost
416	416	25 of any coverage for breast tomosynthesis outlined in this
417	417	26 paragraph, then the requirement that an insurer cover breast
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428	428	1 tomosynthesis is inoperative other than any such coverage
429	429	2 authorized under Section 1902 of the Social Security Act, 42
430	430	3 U.S.C. 1396a, and the State shall not assume any obligation
431	431	4 for the cost of coverage for breast tomosynthesis set forth in
432	432	5 this paragraph.
433	433	6 On and after January 1, 2016, the Department shall ensure
434	434	7 that all networks of care for adult clients of the Department
435	435	8 include access to at least one breast imaging Center of
436	436	9 Imaging Excellence as certified by the American College of
437	437	10 Radiology.
438	438	11 On and after January 1, 2012, providers participating in a
439	439	12 quality improvement program approved by the Department shall
440	440	13 be reimbursed for screening and diagnostic mammography at the
441	441	14 same rate as the Medicare program's rates, including the
442	442	15 increased reimbursement for digital mammography and, after
443	443	16 January 1, 2023 (the effective date of Public Act 102-1018),
444	444	17 breast tomosynthesis.
445	445	18 The Department shall convene an expert panel including
446	446	19 representatives of hospitals, free-standing mammography
447	447	20 facilities, and doctors, including radiologists, to establish
448	448	21 quality standards for mammography.
449	449	22 On and after January 1, 2017, providers participating in a
450	450	23 breast cancer treatment quality improvement program approved
451	451	24 by the Department shall be reimbursed for breast cancer
452	452	25 treatment at a rate that is no lower than 95% of the Medicare
453	453	26 program's rates for the data elements included in the breast
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464	464	1 cancer treatment quality program.
465	465	2 The Department shall convene an expert panel, including
466	466	3 representatives of hospitals, free-standing breast cancer
467	467	4 treatment centers, breast cancer quality organizations, and
468	468	5 doctors, including radiologists that are trained in all forms
469	469	6 of FDA-approved FDA approved breast imaging technologies,
470	470	7 breast surgeons, reconstructive breast surgeons, oncologists,
471	471	8 and primary care providers to establish quality standards for
472	472	9 breast cancer treatment.
473	473	10 Subject to federal approval, the Department shall
474	474	11 establish a rate methodology for mammography at federally
475	475	12 qualified health centers and other encounter-rate clinics.
476	476	13 These clinics or centers may also collaborate with other
477	477	14 hospital-based mammography facilities. By January 1, 2016, the
478	478	15 Department shall report to the General Assembly on the status
479	479	16 of the provision set forth in this paragraph.
480	480	17 The Department shall establish a methodology to remind
481	481	18 individuals who are age-appropriate for screening mammography,
482	482	19 but who have not received a mammogram within the previous 18
483	483	20 months, of the importance and benefit of screening
484	484	21 mammography. The Department shall work with experts in breast
485	485	22 cancer outreach and patient navigation to optimize these
486	486	23 reminders and shall establish a methodology for evaluating
487	487	24 their effectiveness and modifying the methodology based on the
488	488	25 evaluation.
489	489	26 The Department shall establish a performance goal for
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500	500	1 primary care providers with respect to their female patients
501	501	2 over age 40 receiving an annual mammogram. This performance
502	502	3 goal shall be used to provide additional reimbursement in the
503	503	4 form of a quality performance bonus to primary care providers
504	504	5 who meet that goal.
505	505	6 The Department shall devise a means of case-managing or
506	506	7 patient navigation for beneficiaries diagnosed with breast
507	507	8 cancer. This program shall initially operate as a pilot
508	508	9 program in areas of the State with the highest incidence of
509	509	10 mortality related to breast cancer. At least one pilot program
510	510	11 site shall be in the metropolitan Chicago area and at least one
511	511	12 site shall be outside the metropolitan Chicago area. On or
512	512	13 after July 1, 2016, the pilot program shall be expanded to
513	513	14 include one site in western Illinois, one site in southern
514	514	15 Illinois, one site in central Illinois, and 4 sites within
515	515	16 metropolitan Chicago. An evaluation of the pilot program shall
516	516	17 be carried out measuring health outcomes and cost of care for
517	517	18 those served by the pilot program compared to similarly
518	518	19 situated patients who are not served by the pilot program.
519	519	20 The Department shall require all networks of care to
520	520	21 develop a means either internally or by contract with experts
521	521	22 in navigation and community outreach to navigate cancer
522	522	23 patients to comprehensive care in a timely fashion. The
523	523	24 Department shall require all networks of care to include
524	524	25 access for patients diagnosed with cancer to at least one
525	525	26 academic commission on cancer-accredited cancer program as an
526	526
527	527
528	528
529	529
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536	536	1 in-network covered benefit.
537	537	2 The Department shall provide coverage and reimbursement
538	538	3 for a human papillomavirus (HPV) vaccine that is approved for
539	539	4 marketing by the federal Food and Drug Administration for all
540	540	5 persons between the ages of 9 and 45. Subject to federal
541	541	6 approval, the Department shall provide coverage and
542	542	7 reimbursement for a human papillomavirus (HPV) vaccine for
543	543	8 persons of the age of 46 and above who have been diagnosed with
544	544	9 cervical dysplasia with a high risk of recurrence or
545	545	10 progression. The Department shall disallow any
546	546	11 preauthorization requirements for the administration of the
547	547	12 human papillomavirus (HPV) vaccine.
548	548	13 On or after July 1, 2022, individuals who are otherwise
549	549	14 eligible for medical assistance under this Article shall
550	550	15 receive coverage for perinatal depression screenings for the
551	551	16 12-month period beginning on the last day of their pregnancy.
552	552	17 Medical assistance coverage under this paragraph shall be
553	553	18 conditioned on the use of a screening instrument approved by
554	554	19 the Department.
555	555	20 Any medical or health care provider shall immediately
556	556	21 recommend, to any pregnant individual who is being provided
557	557	22 prenatal services and is suspected of having a substance use
558	558	23 disorder as defined in the Substance Use Disorder Act,
559	559	24 referral to a local substance use disorder treatment program
560	560	25 licensed by the Department of Human Services or to a licensed
561	561	26 hospital which provides substance abuse treatment services.
562	562
563	563
564	564
565	565
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572	572	1 The Department of Healthcare and Family Services shall assure
573	573	2 coverage for the cost of treatment of the drug abuse or
574	574	3 addiction for pregnant recipients in accordance with the
575	575	4 Illinois Medicaid Program in conjunction with the Department
576	576	5 of Human Services.
577	577	6 All medical providers providing medical assistance to
578	578	7 pregnant individuals under this Code shall receive information
579	579	8 from the Department on the availability of services under any
580	580	9 program providing case management services for addicted
581	581	10 individuals, including information on appropriate referrals
582	582	11 for other social services that may be needed by addicted
583	583	12 individuals in addition to treatment for addiction.
584	584	13 The Illinois Department, in cooperation with the
585	585	14 Departments of Human Services (as successor to the Department
586	586	15 of Alcoholism and Substance Abuse) and Public Health, through
587	587	16 a public awareness campaign, may provide information
588	588	17 concerning treatment for alcoholism and drug abuse and
589	589	18 addiction, prenatal health care, and other pertinent programs
590	590	19 directed at reducing the number of drug-affected infants born
591	591	20 to recipients of medical assistance.
592	592	21 Neither the Department of Healthcare and Family Services
593	593	22 nor the Department of Human Services shall sanction the
594	594	23 recipient solely on the basis of the recipient's substance
595	595	24 abuse.
596	596	25 The Illinois Department shall establish such regulations
597	597	26 governing the dispensing of health services under this Article
598	598
599	599
600	600
601	601
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608	608	1 as it shall deem appropriate. The Department should seek the
609	609	2 advice of formal professional advisory committees appointed by
610	610	3 the Director of the Illinois Department for the purpose of
611	611	4 providing regular advice on policy and administrative matters,
612	612	5 information dissemination and educational activities for
613	613	6 medical and health care providers, and consistency in
614	614	7 procedures to the Illinois Department.
615	615	8 The Illinois Department may develop and contract with
616	616	9 Partnerships of medical providers to arrange medical services
617	617	10 for persons eligible under Section 5-2 of this Code.
618	618	11 Implementation of this Section may be by demonstration
619	619	12 projects in certain geographic areas. The Partnership shall be
620	620	13 represented by a sponsor organization. The Department, by
621	621	14 rule, shall develop qualifications for sponsors of
622	622	15 Partnerships. Nothing in this Section shall be construed to
623	623	16 require that the sponsor organization be a medical
624	624	17 organization.
625	625	18 The sponsor must negotiate formal written contracts with
626	626	19 medical providers for physician services, inpatient and
627	627	20 outpatient hospital care, home health services, treatment for
628	628	21 alcoholism and substance abuse, and other services determined
629	629	22 necessary by the Illinois Department by rule for delivery by
630	630	23 Partnerships. Physician services must include prenatal and
631	631	24 obstetrical care. The Illinois Department shall reimburse
632	632	25 medical services delivered by Partnership providers to clients
633	633	26 in target areas according to provisions of this Article and
634	634
635	635
636	636
637	637
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644	644	1 the Illinois Health Finance Reform Act, except that:
645	645	2 (1) Physicians participating in a Partnership and
646	646	3 providing certain services, which shall be determined by
647	647	4 the Illinois Department, to persons in areas covered by
648	648	5 the Partnership may receive an additional surcharge for
649	649	6 such services.
650	650	7 (2) The Department may elect to consider and negotiate
651	651	8 financial incentives to encourage the development of
652	652	9 Partnerships and the efficient delivery of medical care.
653	653	10 (3) Persons receiving medical services through
654	654	11 Partnerships may receive medical and case management
655	655	12 services above the level usually offered through the
656	656	13 medical assistance program.
657	657	14 Medical providers shall be required to meet certain
658	658	15 qualifications to participate in Partnerships to ensure the
659	659	16 delivery of high quality medical services. These
660	660	17 qualifications shall be determined by rule of the Illinois
661	661	18 Department and may be higher than qualifications for
662	662	19 participation in the medical assistance program. Partnership
663	663	20 sponsors may prescribe reasonable additional qualifications
664	664	21 for participation by medical providers, only with the prior
665	665	22 written approval of the Illinois Department.
666	666	23 Nothing in this Section shall limit the free choice of
667	667	24 practitioners, hospitals, and other providers of medical
668	668	25 services by clients. In order to ensure patient freedom of
669	669	26 choice, the Illinois Department shall immediately promulgate
670	670
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672	672
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680	680	1 all rules and take all other necessary actions so that
681	681	2 provided services may be accessed from therapeutically
682	682	3 certified optometrists to the full extent of the Illinois
683	683	4 Optometric Practice Act of 1987 without discriminating between
684	684	5 service providers.
685	685	6 The Department shall apply for a waiver from the United
686	686	7 States Health Care Financing Administration to allow for the
687	687	8 implementation of Partnerships under this Section.
688	688	9 The Illinois Department shall require health care
689	689	10 providers to maintain records that document the medical care
690	690	11 and services provided to recipients of Medical Assistance
691	691	12 under this Article. Such records must be retained for a period
692	692	13 of not less than 6 years from the date of service or as
693	693	14 provided by applicable State law, whichever period is longer,
694	694	15 except that if an audit is initiated within the required
695	695	16 retention period then the records must be retained until the
696	696	17 audit is completed and every exception is resolved. The
697	697	18 Illinois Department shall require health care providers to
698	698	19 make available, when authorized by the patient, in writing,
699	699	20 the medical records in a timely fashion to other health care
700	700	21 providers who are treating or serving persons eligible for
701	701	22 Medical Assistance under this Article. All dispensers of
702	702	23 medical services shall be required to maintain and retain
703	703	24 business and professional records sufficient to fully and
704	704	25 accurately document the nature, scope, details and receipt of
705	705	26 the health care provided to persons eligible for medical
706	706
707	707
708	708
709	709
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712	712
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716	716	1 assistance under this Code, in accordance with regulations
717	717	2 promulgated by the Illinois Department. The rules and
718	718	3 regulations shall require that proof of the receipt of
719	719	4 prescription drugs, dentures, prosthetic devices and
720	720	5 eyeglasses by eligible persons under this Section accompany
721	721	6 each claim for reimbursement submitted by the dispenser of
722	722	7 such medical services. No such claims for reimbursement shall
723	723	8 be approved for payment by the Illinois Department without
724	724	9 such proof of receipt, unless the Illinois Department shall
725	725	10 have put into effect and shall be operating a system of
726	726	11 post-payment audit and review which shall, on a sampling
727	727	12 basis, be deemed adequate by the Illinois Department to assure
728	728	13 that such drugs, dentures, prosthetic devices and eyeglasses
729	729	14 for which payment is being made are actually being received by
730	730	15 eligible recipients. Within 90 days after September 16, 1984
731	731	16 (the effective date of Public Act 83-1439), the Illinois
732	732	17 Department shall establish a current list of acquisition costs
733	733	18 for all prosthetic devices and any other items recognized as
734	734	19 medical equipment and supplies reimbursable under this Article
735	735	20 and shall update such list on a quarterly basis, except that
736	736	21 the acquisition costs of all prescription drugs shall be
737	737	22 updated no less frequently than every 30 days as required by
738	738	23 Section 5-5.12.
739	739	24 Notwithstanding any other law to the contrary, the
740	740	25 Illinois Department shall, within 365 days after July 22, 2013
741	741	26 (the effective date of Public Act 98-104), establish
742	742
743	743
744	744
745	745
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748	748
749	749
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752	752	1 procedures to permit skilled care facilities licensed under
753	753	2 the Nursing Home Care Act to submit monthly billing claims for
754	754	3 reimbursement purposes. Following development of these
755	755	4 procedures, the Department shall, by July 1, 2016, test the
756	756	5 viability of the new system and implement any necessary
757	757	6 operational or structural changes to its information
758	758	7 technology platforms in order to allow for the direct
759	759	8 acceptance and payment of nursing home claims.
760	760	9 Notwithstanding any other law to the contrary, the
761	761	10 Illinois Department shall, within 365 days after August 15,
762	762	11 2014 (the effective date of Public Act 98-963), establish
763	763	12 procedures to permit ID/DD facilities licensed under the ID/DD
764	764	13 Community Care Act and MC/DD facilities licensed under the
765	765	14 MC/DD Act to submit monthly billing claims for reimbursement
766	766	15 purposes. Following development of these procedures, the
767	767	16 Department shall have an additional 365 days to test the
768	768	17 viability of the new system and to ensure that any necessary
769	769	18 operational or structural changes to its information
770	770	19 technology platforms are implemented.
771	771	20 The Illinois Department shall require all dispensers of
772	772	21 medical services, other than an individual practitioner or
773	773	22 group of practitioners, desiring to participate in the Medical
774	774	23 Assistance program established under this Article to disclose
775	775	24 all financial, beneficial, ownership, equity, surety or other
776	776	25 interests in any and all firms, corporations, partnerships,
777	777	26 associations, business enterprises, joint ventures, agencies,
778	778
779	779
780	780
781	781
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784	784
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788	788	1 institutions or other legal entities providing any form of
789	789	2 health care services in this State under this Article.
790	790	3 The Illinois Department may require that all dispensers of
791	791	4 medical services desiring to participate in the medical
792	792	5 assistance program established under this Article disclose,
793	793	6 under such terms and conditions as the Illinois Department may
794	794	7 by rule establish, all inquiries from clients and attorneys
795	795	8 regarding medical bills paid by the Illinois Department, which
796	796	9 inquiries could indicate potential existence of claims or
797	797	10 liens for the Illinois Department.
798	798	11 Enrollment of a vendor shall be subject to a provisional
799	799	12 period and shall be conditional for one year. During the
800	800	13 period of conditional enrollment, the Department may terminate
801	801	14 the vendor's eligibility to participate in, or may disenroll
802	802	15 the vendor from, the medical assistance program without cause.
803	803	16 Unless otherwise specified, such termination of eligibility or
804	804	17 disenrollment is not subject to the Department's hearing
805	805	18 process. However, a disenrolled vendor may reapply without
806	806	19 penalty.
807	807	20 The Department has the discretion to limit the conditional
808	808	21 enrollment period for vendors based upon the category of risk
809	809	22 of the vendor.
810	810	23 Prior to enrollment and during the conditional enrollment
811	811	24 period in the medical assistance program, all vendors shall be
812	812	25 subject to enhanced oversight, screening, and review based on
813	813	26 the risk of fraud, waste, and abuse that is posed by the
814	814
815	815
816	816
817	817
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821	821
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824	824	1 category of risk of the vendor. The Illinois Department shall
825	825	2 establish the procedures for oversight, screening, and review,
826	826	3 which may include, but need not be limited to: criminal and
827	827	4 financial background checks; fingerprinting; license,
828	828	5 certification, and authorization verifications; unscheduled or
829	829	6 unannounced site visits; database checks; prepayment audit
830	830	7 reviews; audits; payment caps; payment suspensions; and other
831	831	8 screening as required by federal or State law.
832	832	9 The Department shall define or specify the following: (i)
833	833	10 by provider notice, the "category of risk of the vendor" for
834	834	11 each type of vendor, which shall take into account the level of
835	835	12 screening applicable to a particular category of vendor under
836	836	13 federal law and regulations; (ii) by rule or provider notice,
837	837	14 the maximum length of the conditional enrollment period for
838	838	15 each category of risk of the vendor; and (iii) by rule, the
839	839	16 hearing rights, if any, afforded to a vendor in each category
840	840	17 of risk of the vendor that is terminated or disenrolled during
841	841	18 the conditional enrollment period.
842	842	19 To be eligible for payment consideration, a vendor's
843	843	20 payment claim or bill, either as an initial claim or as a
844	844	21 resubmitted claim following prior rejection, must be received
845	845	22 by the Illinois Department, or its fiscal intermediary, no
846	846	23 later than 180 days after the latest date on the claim on which
847	847	24 medical goods or services were provided, with the following
848	848	25 exceptions:
849	849	26 (1) In the case of a provider whose enrollment is in
850	850
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860	860	1 process by the Illinois Department, the 180-day period
861	861	2 shall not begin until the date on the written notice from
862	862	3 the Illinois Department that the provider enrollment is
863	863	4 complete.
864	864	5 (2) In the case of errors attributable to the Illinois
865	865	6 Department or any of its claims processing intermediaries
866	866	7 which result in an inability to receive, process, or
867	867	8 adjudicate a claim, the 180-day period shall not begin
868	868	9 until the provider has been notified of the error.
869	869	10 (3) In the case of a provider for whom the Illinois
870	870	11 Department initiates the monthly billing process.
871	871	12 (4) In the case of a provider operated by a unit of
872	872	13 local government with a population exceeding 3,000,000
873	873	14 when local government funds finance federal participation
874	874	15 for claims payments.
875	875	16 For claims for services rendered during a period for which
876	876	17 a recipient received retroactive eligibility, claims must be
877	877	18 filed within 180 days after the Department determines the
878	878	19 applicant is eligible. For claims for which the Illinois
879	879	20 Department is not the primary payer, claims must be submitted
880	880	21 to the Illinois Department within 180 days after the final
881	881	22 adjudication by the primary payer.
882	882	23 In the case of long term care facilities, within 120
883	883	24 calendar days of receipt by the facility of required
884	884	25 prescreening information, new admissions with associated
885	885	26 admission documents shall be submitted through the Medical
886	886
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889	889
890	890
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896	896	1 Electronic Data Interchange (MEDI) or the Recipient
897	897	2 Eligibility Verification (REV) System or shall be submitted
898	898	3 directly to the Department of Human Services using required
899	899	4 admission forms. Effective September 1, 2014, admission
900	900	5 documents, including all prescreening information, must be
901	901	6 submitted through MEDI or REV. Confirmation numbers assigned
902	902	7 to an accepted transaction shall be retained by a facility to
903	903	8 verify timely submittal. Once an admission transaction has
904	904	9 been completed, all resubmitted claims following prior
905	905	10 rejection are subject to receipt no later than 180 days after
906	906	11 the admission transaction has been completed.
907	907	12 Claims that are not submitted and received in compliance
908	908	13 with the foregoing requirements shall not be eligible for
909	909	14 payment under the medical assistance program, and the State
910	910	15 shall have no liability for payment of those claims.
911	911	16 To the extent consistent with applicable information and
912	912	17 privacy, security, and disclosure laws, State and federal
913	913	18 agencies and departments shall provide the Illinois Department
914	914	19 access to confidential and other information and data
915	915	20 necessary to perform eligibility and payment verifications and
916	916	21 other Illinois Department functions. This includes, but is not
917	917	22 limited to: information pertaining to licensure;
918	918	23 certification; earnings; immigration status; citizenship; wage
919	919	24 reporting; unearned and earned income; pension income;
920	920	25 employment; supplemental security income; social security
921	921	26 numbers; National Provider Identifier (NPI) numbers; the
922	922
923	923
924	924
925	925
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928	928
929	929
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932	932	1 National Practitioner Data Bank (NPDB); program and agency
933	933	2 exclusions; taxpayer identification numbers; tax delinquency;
934	934	3 corporate information; and death records.
935	935	4 The Illinois Department shall enter into agreements with
936	936	5 State agencies and departments, and is authorized to enter
937	937	6 into agreements with federal agencies and departments, under
938	938	7 which such agencies and departments shall share data necessary
939	939	8 for medical assistance program integrity functions and
940	940	9 oversight. The Illinois Department shall develop, in
941	941	10 cooperation with other State departments and agencies, and in
942	942	11 compliance with applicable federal laws and regulations,
943	943	12 appropriate and effective methods to share such data. At a
944	944	13 minimum, and to the extent necessary to provide data sharing,
945	945	14 the Illinois Department shall enter into agreements with State
946	946	15 agencies and departments, and is authorized to enter into
947	947	16 agreements with federal agencies and departments, including,
948	948	17 but not limited to: the Secretary of State; the Department of
949	949	18 Revenue; the Department of Public Health; the Department of
950	950	19 Human Services; and the Department of Financial and
951	951	20 Professional Regulation.
952	952	21 Beginning in fiscal year 2013, the Illinois Department
953	953	22 shall set forth a request for information to identify the
954	954	23 benefits of a pre-payment, post-adjudication, and post-edit
955	955	24 claims system with the goals of streamlining claims processing
956	956	25 and provider reimbursement, reducing the number of pending or
957	957	26 rejected claims, and helping to ensure a more transparent
958	958
959	959
960	960
961	961
962	962
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964	964
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968	968	1 adjudication process through the utilization of: (i) provider
969	969	2 data verification and provider screening technology; and (ii)
970	970	3 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
971	971	4 post-adjudicated predictive modeling with an integrated case
972	972	5 management system with link analysis. Such a request for
973	973	6 information shall not be considered as a request for proposal
974	974	7 or as an obligation on the part of the Illinois Department to
975	975	8 take any action or acquire any products or services.
976	976	9 The Illinois Department shall establish policies,
977	977	10 procedures, standards and criteria by rule for the
978	978	11 acquisition, repair and replacement of orthotic and prosthetic
979	979	12 devices and durable medical equipment. Such rules shall
980	980	13 provide, but not be limited to, the following services: (1)
981	981	14 immediate repair or replacement of such devices by recipients;
982	982	15 and (2) rental, lease, purchase or lease-purchase of durable
983	983	16 medical equipment in a cost-effective manner, taking into
984	984	17 consideration the recipient's medical prognosis, the extent of
985	985	18 the recipient's needs, and the requirements and costs for
986	986	19 maintaining such equipment. Subject to prior approval, such
987	987	20 rules shall enable a recipient to temporarily acquire and use
988	988	21 alternative or substitute devices or equipment pending repairs
989	989	22 or replacements of any device or equipment previously
990	990	23 authorized for such recipient by the Department.
991	991	24 Notwithstanding any provision of Section 5-5f to the contrary,
992	992	25 the Department may, by rule, exempt certain replacement
993	993	26 wheelchair parts from prior approval and, for wheelchairs,
994	994
995	995
996	996
997	997
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1004	1004	1 wheelchair parts, wheelchair accessories, and related seating
1005	1005	2 and positioning items, determine the wholesale price by
1006	1006	3 methods other than actual acquisition costs.
1007	1007	4 The Department shall require, by rule, all providers of
1008	1008	5 durable medical equipment to be accredited by an accreditation
1009	1009	6 organization approved by the federal Centers for Medicare and
1010	1010	7 Medicaid Services and recognized by the Department in order to
1011	1011	8 bill the Department for providing durable medical equipment to
1012	1012	9 recipients. No later than 15 months after the effective date
1013	1013	10 of the rule adopted pursuant to this paragraph, all providers
1014	1014	11 must meet the accreditation requirement.
1015	1015	12 In order to promote environmental responsibility, meet the
1016	1016	13 needs of recipients and enrollees, and achieve significant
1017	1017	14 cost savings, the Department, or a managed care organization
1018	1018	15 under contract with the Department, may provide recipients or
1019	1019	16 managed care enrollees who have a prescription or Certificate
1020	1020	17 of Medical Necessity access to refurbished durable medical
1021	1021	18 equipment under this Section (excluding prosthetic and
1022	1022	19 orthotic devices as defined in the Orthotics, Prosthetics, and
1023	1023	20 Pedorthics Practice Act and complex rehabilitation technology
1024	1024	21 products and associated services) through the State's
1025	1025	22 assistive technology program's reutilization program, using
1026	1026	23 staff with the Assistive Technology Professional (ATP)
1027	1027	24 Certification if the refurbished durable medical equipment:
1028	1028	25 (i) is available; (ii) is less expensive, including shipping
1029	1029	26 costs, than new durable medical equipment of the same type;
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB2552 - 28 - LRB104 06102 KTG 16135 b
1036	1036
1037	1037
1038	1038	HB2552- 29 -LRB104 06102 KTG 16135 b HB2552 - 29 - LRB104 06102 KTG 16135 b
1039	1039	HB2552 - 29 - LRB104 06102 KTG 16135 b
1040	1040	1 (iii) is able to withstand at least 3 years of use; (iv) is
1041	1041	2 cleaned, disinfected, sterilized, and safe in accordance with
1042	1042	3 federal Food and Drug Administration regulations and guidance
1043	1043	4 governing the reprocessing of medical devices in health care
1044	1044	5 settings; and (v) equally meets the needs of the recipient or
1045	1045	6 enrollee. The reutilization program shall confirm that the
1046	1046	7 recipient or enrollee is not already in receipt of the same or
1047	1047	8 similar equipment from another service provider, and that the
1048	1048	9 refurbished durable medical equipment equally meets the needs
1049	1049	10 of the recipient or enrollee. Nothing in this paragraph shall
1050	1050	11 be construed to limit recipient or enrollee choice to obtain
1051	1051	12 new durable medical equipment or place any additional prior
1052	1052	13 authorization conditions on enrollees of managed care
1053	1053	14 organizations.
1054	1054	15 The Department shall execute, relative to the nursing home
1055	1055	16 prescreening project, written inter-agency agreements with the
1056	1056	17 Department of Human Services and the Department on Aging, to
1057	1057	18 effect the following: (i) intake procedures and common
1058	1058	19 eligibility criteria for those persons who are receiving
1059	1059	20 non-institutional services; and (ii) the establishment and
1060	1060	21 development of non-institutional services in areas of the
1061	1061	22 State where they are not currently available or are
1062	1062	23 undeveloped; and (iii) notwithstanding any other provision of
1063	1063	24 law, subject to federal approval, on and after July 1, 2012, an
1064	1064	25 increase in the determination of need (DON) scores from 29 to
1065	1065	26 37 for applicants for institutional and home and
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB2552 - 29 - LRB104 06102 KTG 16135 b
1072	1072
1073	1073
1074	1074	HB2552- 30 -LRB104 06102 KTG 16135 b HB2552 - 30 - LRB104 06102 KTG 16135 b
1075	1075	HB2552 - 30 - LRB104 06102 KTG 16135 b
1076	1076	1 community-based long term care; if and only if federal
1077	1077	2 approval is not granted, the Department may, in conjunction
1078	1078	3 with other affected agencies, implement utilization controls
1079	1079	4 or changes in benefit packages to effectuate a similar savings
1080	1080	5 amount for this population; and (iv) no later than July 1,
1081	1081	6 2013, minimum level of care eligibility criteria for
1082	1082	7 institutional and home and community-based long term care; and
1083	1083	8 (v) no later than October 1, 2013, establish procedures to
1084	1084	9 permit long term care providers access to eligibility scores
1085	1085	10 for individuals with an admission date who are seeking or
1086	1086	11 receiving services from the long term care provider. In order
1087	1087	12 to select the minimum level of care eligibility criteria, the
1088	1088	13 Governor shall establish a workgroup that includes affected
1089	1089	14 agency representatives and stakeholders representing the
1090	1090	15 institutional and home and community-based long term care
1091	1091	16 interests. This Section shall not restrict the Department from
1092	1092	17 implementing lower level of care eligibility criteria for
1093	1093	18 community-based services in circumstances where federal
1094	1094	19 approval has been granted.
1095	1095	20 The Illinois Department shall develop and operate, in
1096	1096	21 cooperation with other State Departments and agencies and in
1097	1097	22 compliance with applicable federal laws and regulations,
1098	1098	23 appropriate and effective systems of health care evaluation
1099	1099	24 and programs for monitoring of utilization of health care
1100	1100	25 services and facilities, as it affects persons eligible for
1101	1101	26 medical assistance under this Code.
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB2552 - 30 - LRB104 06102 KTG 16135 b
1108	1108
1109	1109
1110	1110	HB2552- 31 -LRB104 06102 KTG 16135 b HB2552 - 31 - LRB104 06102 KTG 16135 b
1111	1111	HB2552 - 31 - LRB104 06102 KTG 16135 b
1112	1112	1 The Illinois Department shall report annually to the
1113	1113	2 General Assembly, no later than the second Friday in April of
1114	1114	3 1979 and each year thereafter, in regard to:
1115	1115	4 (a) actual statistics and trends in utilization of
1116	1116	5 medical services by public aid recipients;
1117	1117	6 (b) actual statistics and trends in the provision of
1118	1118	7 the various medical services by medical vendors;
1119	1119	8 (c) current rate structures and proposed changes in
1120	1120	9 those rate structures for the various medical vendors; and
1121	1121	10 (d) efforts at utilization review and control by the
1122	1122	11 Illinois Department.
1123	1123	12 The period covered by each report shall be the 3 years
1124	1124	13 ending on the June 30 prior to the report. The report shall
1125	1125	14 include suggested legislation for consideration by the General
1126	1126	15 Assembly. The requirement for reporting to the General
1127	1127	16 Assembly shall be satisfied by filing copies of the report as
1128	1128	17 required by Section 3.1 of the General Assembly Organization
1129	1129	18 Act, and filing such additional copies with the State
1130	1130	19 Government Report Distribution Center for the General Assembly
1131	1131	20 as is required under paragraph (t) of Section 7 of the State
1132	1132	21 Library Act.
1133	1133	22 Rulemaking authority to implement Public Act 95-1045, if
1134	1134	23 any, is conditioned on the rules being adopted in accordance
1135	1135	24 with all provisions of the Illinois Administrative Procedure
1136	1136	25 Act and all rules and procedures of the Joint Committee on
1137	1137	26 Administrative Rules; any purported rule not so adopted, for
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB2552 - 31 - LRB104 06102 KTG 16135 b
1144	1144
1145	1145
1146	1146	HB2552- 32 -LRB104 06102 KTG 16135 b HB2552 - 32 - LRB104 06102 KTG 16135 b
1147	1147	HB2552 - 32 - LRB104 06102 KTG 16135 b
1148	1148	1 whatever reason, is unauthorized.
1149	1149	2 On and after July 1, 2012, the Department shall reduce any
1150	1150	3 rate of reimbursement for services or other payments or alter
1151	1151	4 any methodologies authorized by this Code to reduce any rate
1152	1152	5 of reimbursement for services or other payments in accordance
1153	1153	6 with Section 5-5e.
1154	1154	7 Because kidney transplantation can be an appropriate,
1155	1155	8 cost-effective alternative to renal dialysis when medically
1156	1156	9 necessary and notwithstanding the provisions of Section 1-11
1157	1157	10 of this Code, beginning October 1, 2014, the Department shall
1158	1158	11 cover kidney transplantation for noncitizens with end-stage
1159	1159	12 renal disease who are not eligible for comprehensive medical
1160	1160	13 benefits, who meet the residency requirements of Section 5-3
1161	1161	14 of this Code, and who would otherwise meet the financial
1162	1162	15 requirements of the appropriate class of eligible persons
1163	1163	16 under Section 5-2 of this Code. To qualify for coverage of
1164	1164	17 kidney transplantation, such person must be receiving
1165	1165	18 emergency renal dialysis services covered by the Department.
1166	1166	19 Providers under this Section shall be prior approved and
1167	1167	20 certified by the Department to perform kidney transplantation
1168	1168	21 and the services under this Section shall be limited to
1169	1169	22 services associated with kidney transplantation.
1170	1170	23 Notwithstanding any other provision of this Code to the
1171	1171	24 contrary, on or after July 1, 2015, all FDA-approved FDA
1172	1172	25 approved forms of medication assisted treatment prescribed for
1173	1173	26 the treatment of alcohol dependence or treatment of opioid
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB2552 - 32 - LRB104 06102 KTG 16135 b
1180	1180
1181	1181
1182	1182	HB2552- 33 -LRB104 06102 KTG 16135 b HB2552 - 33 - LRB104 06102 KTG 16135 b
1183	1183	HB2552 - 33 - LRB104 06102 KTG 16135 b
1184	1184	1 dependence shall be covered under both fee-for-service and
1185	1185	2 managed care medical assistance programs for persons who are
1186	1186	3 otherwise eligible for medical assistance under this Article
1187	1187	4 and shall not be subject to any (1) utilization control, other
1188	1188	5 than those established under the American Society of Addiction
1189	1189	6 Medicine patient placement criteria, (2) prior authorization
1190	1190	7 mandate, (3) lifetime restriction limit mandate, or (4)
1191	1191	8 limitations on dosage.
1192	1192	9 On or after July 1, 2015, opioid antagonists prescribed
1193	1193	10 for the treatment of an opioid overdose, including the
1194	1194	11 medication product, administration devices, and any pharmacy
1195	1195	12 fees or hospital fees related to the dispensing, distribution,
1196	1196	13 and administration of the opioid antagonist, shall be covered
1197	1197	14 under the medical assistance program for persons who are
1198	1198	15 otherwise eligible for medical assistance under this Article.
1199	1199	16 As used in this Section, "opioid antagonist" means a drug that
1200	1200	17 binds to opioid receptors and blocks or inhibits the effect of
1201	1201	18 opioids acting on those receptors, including, but not limited
1202	1202	19 to, naloxone hydrochloride or any other similarly acting drug
1203	1203	20 approved by the U.S. Food and Drug Administration. The
1204	1204	21 Department shall not impose a copayment on the coverage
1205	1205	22 provided for naloxone hydrochloride under the medical
1206	1206	23 assistance program.
1207	1207	24 Upon federal approval, the Department shall provide
1208	1208	25 coverage and reimbursement for all drugs that are approved for
1209	1209	26 marketing by the federal Food and Drug Administration and that
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB2552 - 33 - LRB104 06102 KTG 16135 b
1216	1216
1217	1217
1218	1218	HB2552- 34 -LRB104 06102 KTG 16135 b HB2552 - 34 - LRB104 06102 KTG 16135 b
1219	1219	HB2552 - 34 - LRB104 06102 KTG 16135 b
1220	1220	1 are recommended by the federal Public Health Service or the
1221	1221	2 United States Centers for Disease Control and Prevention for
1222	1222	3 pre-exposure prophylaxis and related pre-exposure prophylaxis
1223	1223	4 services, including, but not limited to, HIV and sexually
1224	1224	5 transmitted infection screening, treatment for sexually
1225	1225	6 transmitted infections, medical monitoring, assorted labs, and
1226	1226	7 counseling to reduce the likelihood of HIV infection among
1227	1227	8 individuals who are not infected with HIV but who are at high
1228	1228	9 risk of HIV infection.
1229	1229	10 A federally qualified health center, as defined in Section
1230	1230	11 1905(l)(2)(B) of the federal Social Security Act, shall be
1231	1231	12 reimbursed by the Department in accordance with the federally
1232	1232	13 qualified health center's encounter rate for services provided
1233	1233	14 to medical assistance recipients that are performed by a
1234	1234	15 dental hygienist, as defined under the Illinois Dental
1235	1235	16 Practice Act, working under the general supervision of a
1236	1236	17 dentist and employed by a federally qualified health center.
1237	1237	18 Within 90 days after October 8, 2021 (the effective date
1238	1238	19 of Public Act 102-665), the Department shall seek federal
1239	1239	20 approval of a State Plan amendment to expand coverage for
1240	1240	21 family planning services that includes presumptive eligibility
1241	1241	22 to individuals whose income is at or below 208% of the federal
1242	1242	23 poverty level. Coverage under this Section shall be effective
1243	1243	24 beginning no later than December 1, 2022.
1244	1244	25 Subject to approval by the federal Centers for Medicare
1245	1245	26 and Medicaid Services of a Title XIX State Plan amendment
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
1251	1251	HB2552 - 34 - LRB104 06102 KTG 16135 b
1252	1252
1253	1253
1254	1254	HB2552- 35 -LRB104 06102 KTG 16135 b HB2552 - 35 - LRB104 06102 KTG 16135 b
1255	1255	HB2552 - 35 - LRB104 06102 KTG 16135 b
1256	1256	1 electing the Program of All-Inclusive Care for the Elderly
1257	1257	2 (PACE) as a State Medicaid option, as provided for by Subtitle
1258	1258	3 I (commencing with Section 4801) of Title IV of the Balanced
1259	1259	4 Budget Act of 1997 (Public Law 105-33) and Part 460
1260	1260	5 (commencing with Section 460.2) of Subchapter E of Title 42 of
1261	1261	6 the Code of Federal Regulations, PACE program services shall
1262	1262	7 become a covered benefit of the medical assistance program,
1263	1263	8 subject to criteria established in accordance with all
1264	1264	9 applicable laws.
1265	1265	10 Notwithstanding any other provision of this Code,
1266	1266	11 community-based pediatric palliative care from a trained
1267	1267	12 interdisciplinary team shall be covered under the medical
1268	1268	13 assistance program as provided in Section 15 of the Pediatric
1269	1269	14 Palliative Care Act.
1270	1270	15 Notwithstanding any other provision of this Code, within
1271	1271	16 12 months after June 2, 2022 (the effective date of Public Act
1272	1272	17 102-1037) and subject to federal approval, acupuncture
1273	1273	18 services performed by an acupuncturist licensed under the
1274	1274	19 Acupuncture Practice Act who is acting within the scope of his
1275	1275	20 or her license shall be covered under the medical assistance
1276	1276	21 program. The Department shall apply for any federal waiver or
1277	1277	22 State Plan amendment, if required, to implement this
1278	1278	23 paragraph. The Department may adopt any rules, including
1279	1279	24 standards and criteria, necessary to implement this paragraph.
1280	1280	25 Notwithstanding any other provision of this Code, the
1281	1281	26 medical assistance program shall, subject to federal approval,
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
1287	1287	HB2552 - 35 - LRB104 06102 KTG 16135 b
1288	1288
1289	1289
1290	1290	HB2552- 36 -LRB104 06102 KTG 16135 b HB2552 - 36 - LRB104 06102 KTG 16135 b
1291	1291	HB2552 - 36 - LRB104 06102 KTG 16135 b
1292	1292	1 reimburse hospitals for costs associated with a newborn
1293	1293	2 screening test for the presence of metachromatic
1294	1294	3 leukodystrophy, as required under the Newborn Metabolic
1295	1295	4 Screening Act, at a rate not less than the fee charged by the
1296	1296	5 Department of Public Health. Notwithstanding any other
1297	1297	6 provision of this Code, the medical assistance program shall,
1298	1298	7 subject to appropriation and federal approval, also reimburse
1299	1299	8 hospitals for costs associated with all newborn screening
1300	1300	9 tests added on and after August 9, 2024 (the effective date of
1301	1301	10 Public Act 103-909) this amendatory Act of the 103rd General
1302	1302	11 Assembly to the Newborn Metabolic Screening Act and required
1303	1303	12 to be performed under that Act at a rate not less than the fee
1304	1304	13 charged by the Department of Public Health. The Department
1305	1305	14 shall seek federal approval before the implementation of the
1306	1306	15 newborn screening test fees by the Department of Public
1307	1307	16 Health.
1308	1308	17 Notwithstanding any other provision of this Code,
1309	1309	18 beginning on January 1, 2024, subject to federal approval,
1310	1310	19 cognitive assessment and care planning services provided to a
1311	1311	20 person who experiences signs or symptoms of cognitive
1312	1312	21 impairment, as defined by the Diagnostic and Statistical
1313	1313	22 Manual of Mental Disorders, Fifth Edition, shall be covered
1314	1314	23 under the medical assistance program for persons who are
1315	1315	24 otherwise eligible for medical assistance under this Article.
1316	1316	25 Notwithstanding any other provision of this Code,
1317	1317	26 medically necessary reconstructive services that are intended
1318	1318
1319	1319
1320	1320
1321	1321
1322	1322
1323	1323	HB2552 - 36 - LRB104 06102 KTG 16135 b
1324	1324
1325	1325
1326	1326	HB2552- 37 -LRB104 06102 KTG 16135 b HB2552 - 37 - LRB104 06102 KTG 16135 b
1327	1327	HB2552 - 37 - LRB104 06102 KTG 16135 b
1328	1328	1 to restore physical appearance shall be covered under the
1329	1329	2 medical assistance program for persons who are otherwise
1330	1330	3 eligible for medical assistance under this Article. As used in
1331	1331	4 this paragraph, "reconstructive services" means treatments
1332	1332	5 performed on structures of the body damaged by trauma to
1333	1333	6 restore physical appearance.
1334	1334	7 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1335	1335	8 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1336	1336	9 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1337	1337	10 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1338	1338	11 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1339	1339	12 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1340	1340	13 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1341	1341	14 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1342	1342	15 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1343	1343	16 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
1344	1344	17 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
1345	1345	18 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
1346	1346	19 8-9-24; revised 10-10-24.)
1347	1347
1348	1348
1349	1349
1350	1350
1351	1351
1352	1352	HB2552 - 37 - LRB104 06102 KTG 16135 b