Illinois 2025-2026 Regular Session

Illinois House Bill HB2554 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 HB2554 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 rates paid for children's dental comprehensive oral exams, periodic oral exams, problem focused exams, behavior management codes, sealants, resin-based composites-posterior teeth, and extraction and surgical extraction codes shall be increased by 33% above the rates in effect on December 31, 2025. Effective January 1, 2026. LRB104 06104 KTG 16137 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2554 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 rates paid for children's dental comprehensive oral exams, periodic oral exams, problem focused exams, behavior management codes, sealants, resin-based composites-posterior teeth, and extraction and surgical extraction codes shall be increased by 33% above the rates in effect on December 31, 2025. Effective January 1, 2026. LRB104 06104 KTG 16137 b LRB104 06104 KTG 16137 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2554 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 rates paid for children's dental comprehensive oral exams, periodic oral exams, problem focused exams, behavior management codes, sealants, resin-based composites-posterior teeth, and extraction and surgical extraction codes shall be increased by 33% above the rates in effect on December 31, 2025. Effective January 1, 2026.
6	6	LRB104 06104 KTG 16137 b LRB104 06104 KTG 16137 b
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8	8	A BILL FOR
9	9	HB2554LRB104 06104 KTG 16137 b HB2554 LRB104 06104 KTG 16137 b
10	10	HB2554 LRB104 06104 KTG 16137 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 HB2554 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 rates paid for children's dental comprehensive oral exams, periodic oral exams, problem focused exams, behavior management codes, sealants, resin-based composites-posterior teeth, and extraction and surgical extraction codes shall be increased by 33% above the rates in effect on December 31, 2025. Effective January 1, 2026.
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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 rates paid for
300	300	17 children's dental comprehensive oral exams, periodic oral
301	301	18 exams, problem focused exams, behavior management codes,
302	302	19 sealants, resin-based composites-posterior teeth, and
303	303	20 extraction and surgical extraction codes shall be increased by
304	304	21 33% above the rates in effect on December 31, 2025.
305	305	22 The Illinois Department, by rule, may distinguish and
306	306	23 classify the medical services to be provided only in
307	307	24 accordance with the classes of persons designated in Section
308	308	25 5-2.
309	309	26 The Department of Healthcare and Family Services must
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320	320	1 provide coverage and reimbursement for amino acid-based
321	321	2 elemental formulas, regardless of delivery method, for the
322	322	3 diagnosis and treatment of (i) eosinophilic disorders and (ii)
323	323	4 short bowel syndrome when the prescribing physician has issued
324	324	5 a written order stating that the amino acid-based elemental
325	325	6 formula is medically necessary.
326	326	7 The Illinois Department shall authorize the provision of,
327	327	8 and shall authorize payment for, screening by low-dose
328	328	9 mammography for the presence of occult breast cancer for
329	329	10 individuals 35 years of age or older who are eligible for
330	330	11 medical assistance under this Article, as follows:
331	331	12 (A) A baseline mammogram for individuals 35 to 39
332	332	13 years of age.
333	333	14 (B) An annual mammogram for individuals 40 years of
334	334	15 age or older.
335	335	16 (C) A mammogram at the age and intervals considered
336	336	17 medically necessary by the individual's health care
337	337	18 provider for individuals under 40 years of age and having
338	338	19 a family history of breast cancer, prior personal history
339	339	20 of breast cancer, positive genetic testing, or other risk
340	340	21 factors.
341	341	22 (D) A comprehensive ultrasound screening and MRI of an
342	342	23 entire breast or breasts if a mammogram demonstrates
343	343	24 heterogeneous or dense breast tissue or when medically
344	344	25 necessary as determined by a physician licensed to
345	345	26 practice medicine in all of its branches.
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356	356	1 (E) A screening MRI when medically necessary, as
357	357	2 determined by a physician licensed to practice medicine in
358	358	3 all of its branches.
359	359	4 (F) A diagnostic mammogram when medically necessary,
360	360	5 as determined by a physician licensed to practice medicine
361	361	6 in all its branches, advanced practice registered nurse,
362	362	7 or physician assistant.
363	363	8 (G) Molecular breast imaging (MBI) and MRI of an
364	364	9 entire breast or breasts if a mammogram demonstrates
365	365	10 heterogeneous or dense breast tissue or when medically
366	366	11 necessary as determined by a physician licensed to
367	367	12 practice medicine in all of its branches, advanced
368	368	13 practice registered nurse, or physician assistant.
369	369	14 The Department shall not impose a deductible, coinsurance,
370	370	15 copayment, or any other cost-sharing requirement on the
371	371	16 coverage provided under this paragraph; except that this
372	372	17 sentence does not apply to coverage of diagnostic mammograms
373	373	18 to the extent such coverage would disqualify a high-deductible
374	374	19 health plan from eligibility for a health savings account
375	375	20 pursuant to Section 223 of the Internal Revenue Code (26
376	376	21 U.S.C. 223).
377	377	22 All screenings shall include a physical breast exam,
378	378	23 instruction on self-examination and information regarding the
379	379	24 frequency of self-examination and its value as a preventative
380	380	25 tool.
381	381	26 For purposes of this Section:
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392	392	1 "Diagnostic mammogram" means a mammogram obtained using
393	393	2 diagnostic mammography.
394	394	3 "Diagnostic mammography" means a method of screening that
395	395	4 is designed to evaluate an abnormality in a breast, including
396	396	5 an abnormality seen or suspected on a screening mammogram or a
397	397	6 subjective or objective abnormality otherwise detected in the
398	398	7 breast.
399	399	8 "Low-dose mammography" means the x-ray examination of the
400	400	9 breast using equipment dedicated specifically for mammography,
401	401	10 including the x-ray tube, filter, compression device, and
402	402	11 image receptor, with an average radiation exposure delivery of
403	403	12 less than one rad per breast for 2 views of an average size
404	404	13 breast. The term also includes digital mammography and
405	405	14 includes breast tomosynthesis.
406	406	15 "Breast tomosynthesis" means a radiologic procedure that
407	407	16 involves the acquisition of projection images over the
408	408	17 stationary breast to produce cross-sectional digital
409	409	18 three-dimensional images of the breast.
410	410	19 If, at any time, the Secretary of the United States
411	411	20 Department of Health and Human Services, or its successor
412	412	21 agency, promulgates rules or regulations to be published in
413	413	22 the Federal Register or publishes a comment in the Federal
414	414	23 Register or issues an opinion, guidance, or other action that
415	415	24 would require the State, pursuant to any provision of the
416	416	25 Patient Protection and Affordable Care Act (Public Law
417	417	26 111-148), including, but not limited to, 42 U.S.C.
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428	428	1 18031(d)(3)(B) or any successor provision, to defray the cost
429	429	2 of any coverage for breast tomosynthesis outlined in this
430	430	3 paragraph, then the requirement that an insurer cover breast
431	431	4 tomosynthesis is inoperative other than any such coverage
432	432	5 authorized under Section 1902 of the Social Security Act, 42
433	433	6 U.S.C. 1396a, and the State shall not assume any obligation
434	434	7 for the cost of coverage for breast tomosynthesis set forth in
435	435	8 this paragraph.
436	436	9 On and after January 1, 2016, the Department shall ensure
437	437	10 that all networks of care for adult clients of the Department
438	438	11 include access to at least one breast imaging Center of
439	439	12 Imaging Excellence as certified by the American College of
440	440	13 Radiology.
441	441	14 On and after January 1, 2012, providers participating in a
442	442	15 quality improvement program approved by the Department shall
443	443	16 be reimbursed for screening and diagnostic mammography at the
444	444	17 same rate as the Medicare program's rates, including the
445	445	18 increased reimbursement for digital mammography and, after
446	446	19 January 1, 2023 (the effective date of Public Act 102-1018),
447	447	20 breast tomosynthesis.
448	448	21 The Department shall convene an expert panel including
449	449	22 representatives of hospitals, free-standing mammography
450	450	23 facilities, and doctors, including radiologists, to establish
451	451	24 quality standards for mammography.
452	452	25 On and after January 1, 2017, providers participating in a
453	453	26 breast cancer treatment quality improvement program approved
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464	464	1 by the Department shall be reimbursed for breast cancer
465	465	2 treatment at a rate that is no lower than 95% of the Medicare
466	466	3 program's rates for the data elements included in the breast
467	467	4 cancer treatment quality program.
468	468	5 The Department shall convene an expert panel, including
469	469	6 representatives of hospitals, free-standing breast cancer
470	470	7 treatment centers, breast cancer quality organizations, and
471	471	8 doctors, including radiologists that are trained in all forms
472	472	9 of FDA-approved FDA approved breast imaging technologies,
473	473	10 breast surgeons, reconstructive breast surgeons, oncologists,
474	474	11 and primary care providers to establish quality standards for
475	475	12 breast cancer treatment.
476	476	13 Subject to federal approval, the Department shall
477	477	14 establish a rate methodology for mammography at federally
478	478	15 qualified health centers and other encounter-rate clinics.
479	479	16 These clinics or centers may also collaborate with other
480	480	17 hospital-based mammography facilities. By January 1, 2016, the
481	481	18 Department shall report to the General Assembly on the status
482	482	19 of the provision set forth in this paragraph.
483	483	20 The Department shall establish a methodology to remind
484	484	21 individuals who are age-appropriate for screening mammography,
485	485	22 but who have not received a mammogram within the previous 18
486	486	23 months, of the importance and benefit of screening
487	487	24 mammography. The Department shall work with experts in breast
488	488	25 cancer outreach and patient navigation to optimize these
489	489	26 reminders and shall establish a methodology for evaluating
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500	500	1 their effectiveness and modifying the methodology based on the
501	501	2 evaluation.
502	502	3 The Department shall establish a performance goal for
503	503	4 primary care providers with respect to their female patients
504	504	5 over age 40 receiving an annual mammogram. This performance
505	505	6 goal shall be used to provide additional reimbursement in the
506	506	7 form of a quality performance bonus to primary care providers
507	507	8 who meet that goal.
508	508	9 The Department shall devise a means of case-managing or
509	509	10 patient navigation for beneficiaries diagnosed with breast
510	510	11 cancer. This program shall initially operate as a pilot
511	511	12 program in areas of the State with the highest incidence of
512	512	13 mortality related to breast cancer. At least one pilot program
513	513	14 site shall be in the metropolitan Chicago area and at least one
514	514	15 site shall be outside the metropolitan Chicago area. On or
515	515	16 after July 1, 2016, the pilot program shall be expanded to
516	516	17 include one site in western Illinois, one site in southern
517	517	18 Illinois, one site in central Illinois, and 4 sites within
518	518	19 metropolitan Chicago. An evaluation of the pilot program shall
519	519	20 be carried out measuring health outcomes and cost of care for
520	520	21 those served by the pilot program compared to similarly
521	521	22 situated patients who are not served by the pilot program.
522	522	23 The Department shall require all networks of care to
523	523	24 develop a means either internally or by contract with experts
524	524	25 in navigation and community outreach to navigate cancer
525	525	26 patients to comprehensive care in a timely fashion. The
526	526
527	527
528	528
529	529
530	530
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532	532
533	533
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536	536	1 Department shall require all networks of care to include
537	537	2 access for patients diagnosed with cancer to at least one
538	538	3 academic commission on cancer-accredited cancer program as an
539	539	4 in-network covered benefit.
540	540	5 The Department shall provide coverage and reimbursement
541	541	6 for a human papillomavirus (HPV) vaccine that is approved for
542	542	7 marketing by the federal Food and Drug Administration for all
543	543	8 persons between the ages of 9 and 45. Subject to federal
544	544	9 approval, the Department shall provide coverage and
545	545	10 reimbursement for a human papillomavirus (HPV) vaccine for
546	546	11 persons of the age of 46 and above who have been diagnosed with
547	547	12 cervical dysplasia with a high risk of recurrence or
548	548	13 progression. The Department shall disallow any
549	549	14 preauthorization requirements for the administration of the
550	550	15 human papillomavirus (HPV) vaccine.
551	551	16 On or after July 1, 2022, individuals who are otherwise
552	552	17 eligible for medical assistance under this Article shall
553	553	18 receive coverage for perinatal depression screenings for the
554	554	19 12-month period beginning on the last day of their pregnancy.
555	555	20 Medical assistance coverage under this paragraph shall be
556	556	21 conditioned on the use of a screening instrument approved by
557	557	22 the Department.
558	558	23 Any medical or health care provider shall immediately
559	559	24 recommend, to any pregnant individual who is being provided
560	560	25 prenatal services and is suspected of having a substance use
561	561	26 disorder as defined in the Substance Use Disorder Act,
562	562
563	563
564	564
565	565
566	566
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568	568
569	569
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571	571	HB2554 - 16 - LRB104 06104 KTG 16137 b
572	572	1 referral to a local substance use disorder treatment program
573	573	2 licensed by the Department of Human Services or to a licensed
574	574	3 hospital which provides substance abuse treatment services.
575	575	4 The Department of Healthcare and Family Services shall assure
576	576	5 coverage for the cost of treatment of the drug abuse or
577	577	6 addiction for pregnant recipients in accordance with the
578	578	7 Illinois Medicaid Program in conjunction with the Department
579	579	8 of Human Services.
580	580	9 All medical providers providing medical assistance to
581	581	10 pregnant individuals under this Code shall receive information
582	582	11 from the Department on the availability of services under any
583	583	12 program providing case management services for addicted
584	584	13 individuals, including information on appropriate referrals
585	585	14 for other social services that may be needed by addicted
586	586	15 individuals in addition to treatment for addiction.
587	587	16 The Illinois Department, in cooperation with the
588	588	17 Departments of Human Services (as successor to the Department
589	589	18 of Alcoholism and Substance Abuse) and Public Health, through
590	590	19 a public awareness campaign, may provide information
591	591	20 concerning treatment for alcoholism and drug abuse and
592	592	21 addiction, prenatal health care, and other pertinent programs
593	593	22 directed at reducing the number of drug-affected infants born
594	594	23 to recipients of medical assistance.
595	595	24 Neither the Department of Healthcare and Family Services
596	596	25 nor the Department of Human Services shall sanction the
597	597	26 recipient solely on the basis of the recipient's substance
598	598
599	599
600	600
601	601
602	602
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604	604
605	605
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608	608	1 abuse.
609	609	2 The Illinois Department shall establish such regulations
610	610	3 governing the dispensing of health services under this Article
611	611	4 as it shall deem appropriate. The Department should seek the
612	612	5 advice of formal professional advisory committees appointed by
613	613	6 the Director of the Illinois Department for the purpose of
614	614	7 providing regular advice on policy and administrative matters,
615	615	8 information dissemination and educational activities for
616	616	9 medical and health care providers, and consistency in
617	617	10 procedures to the Illinois Department.
618	618	11 The Illinois Department may develop and contract with
619	619	12 Partnerships of medical providers to arrange medical services
620	620	13 for persons eligible under Section 5-2 of this Code.
621	621	14 Implementation of this Section may be by demonstration
622	622	15 projects in certain geographic areas. The Partnership shall be
623	623	16 represented by a sponsor organization. The Department, by
624	624	17 rule, shall develop qualifications for sponsors of
625	625	18 Partnerships. Nothing in this Section shall be construed to
626	626	19 require that the sponsor organization be a medical
627	627	20 organization.
628	628	21 The sponsor must negotiate formal written contracts with
629	629	22 medical providers for physician services, inpatient and
630	630	23 outpatient hospital care, home health services, treatment for
631	631	24 alcoholism and substance abuse, and other services determined
632	632	25 necessary by the Illinois Department by rule for delivery by
633	633	26 Partnerships. Physician services must include prenatal and
634	634
635	635
636	636
637	637
638	638
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640	640
641	641
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643	643	HB2554 - 18 - LRB104 06104 KTG 16137 b
644	644	1 obstetrical care. The Illinois Department shall reimburse
645	645	2 medical services delivered by Partnership providers to clients
646	646	3 in target areas according to provisions of this Article and
647	647	4 the Illinois Health Finance Reform Act, except that:
648	648	5 (1) Physicians participating in a Partnership and
649	649	6 providing certain services, which shall be determined by
650	650	7 the Illinois Department, to persons in areas covered by
651	651	8 the Partnership may receive an additional surcharge for
652	652	9 such services.
653	653	10 (2) The Department may elect to consider and negotiate
654	654	11 financial incentives to encourage the development of
655	655	12 Partnerships and the efficient delivery of medical care.
656	656	13 (3) Persons receiving medical services through
657	657	14 Partnerships may receive medical and case management
658	658	15 services above the level usually offered through the
659	659	16 medical assistance program.
660	660	17 Medical providers shall be required to meet certain
661	661	18 qualifications to participate in Partnerships to ensure the
662	662	19 delivery of high quality medical services. These
663	663	20 qualifications shall be determined by rule of the Illinois
664	664	21 Department and may be higher than qualifications for
665	665	22 participation in the medical assistance program. Partnership
666	666	23 sponsors may prescribe reasonable additional qualifications
667	667	24 for participation by medical providers, only with the prior
668	668	25 written approval of the Illinois Department.
669	669	26 Nothing in this Section shall limit the free choice of
670	670
671	671
672	672
673	673
674	674
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676	676
677	677
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679	679	HB2554 - 19 - LRB104 06104 KTG 16137 b
680	680	1 practitioners, hospitals, and other providers of medical
681	681	2 services by clients. In order to ensure patient freedom of
682	682	3 choice, the Illinois Department shall immediately promulgate
683	683	4 all rules and take all other necessary actions so that
684	684	5 provided services may be accessed from therapeutically
685	685	6 certified optometrists to the full extent of the Illinois
686	686	7 Optometric Practice Act of 1987 without discriminating between
687	687	8 service providers.
688	688	9 The Department shall apply for a waiver from the United
689	689	10 States Health Care Financing Administration to allow for the
690	690	11 implementation of Partnerships under this Section.
691	691	12 The Illinois Department shall require health care
692	692	13 providers to maintain records that document the medical care
693	693	14 and services provided to recipients of Medical Assistance
694	694	15 under this Article. Such records must be retained for a period
695	695	16 of not less than 6 years from the date of service or as
696	696	17 provided by applicable State law, whichever period is longer,
697	697	18 except that if an audit is initiated within the required
698	698	19 retention period then the records must be retained until the
699	699	20 audit is completed and every exception is resolved. The
700	700	21 Illinois Department shall require health care providers to
701	701	22 make available, when authorized by the patient, in writing,
702	702	23 the medical records in a timely fashion to other health care
703	703	24 providers who are treating or serving persons eligible for
704	704	25 Medical Assistance under this Article. All dispensers of
705	705	26 medical services shall be required to maintain and retain
706	706
707	707
708	708
709	709
710	710
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712	712
713	713
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716	716	1 business and professional records sufficient to fully and
717	717	2 accurately document the nature, scope, details and receipt of
718	718	3 the health care provided to persons eligible for medical
719	719	4 assistance under this Code, in accordance with regulations
720	720	5 promulgated by the Illinois Department. The rules and
721	721	6 regulations shall require that proof of the receipt of
722	722	7 prescription drugs, dentures, prosthetic devices and
723	723	8 eyeglasses by eligible persons under this Section accompany
724	724	9 each claim for reimbursement submitted by the dispenser of
725	725	10 such medical services. No such claims for reimbursement shall
726	726	11 be approved for payment by the Illinois Department without
727	727	12 such proof of receipt, unless the Illinois Department shall
728	728	13 have put into effect and shall be operating a system of
729	729	14 post-payment audit and review which shall, on a sampling
730	730	15 basis, be deemed adequate by the Illinois Department to assure
731	731	16 that such drugs, dentures, prosthetic devices and eyeglasses
732	732	17 for which payment is being made are actually being received by
733	733	18 eligible recipients. Within 90 days after September 16, 1984
734	734	19 (the effective date of Public Act 83-1439), the Illinois
735	735	20 Department shall establish a current list of acquisition costs
736	736	21 for all prosthetic devices and any other items recognized as
737	737	22 medical equipment and supplies reimbursable under this Article
738	738	23 and shall update such list on a quarterly basis, except that
739	739	24 the acquisition costs of all prescription drugs shall be
740	740	25 updated no less frequently than every 30 days as required by
741	741	26 Section 5-5.12.
742	742
743	743
744	744
745	745
746	746
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748	748
749	749
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751	751	HB2554 - 21 - LRB104 06104 KTG 16137 b
752	752	1 Notwithstanding any other law to the contrary, the
753	753	2 Illinois Department shall, within 365 days after July 22, 2013
754	754	3 (the effective date of Public Act 98-104), establish
755	755	4 procedures to permit skilled care facilities licensed under
756	756	5 the Nursing Home Care Act to submit monthly billing claims for
757	757	6 reimbursement purposes. Following development of these
758	758	7 procedures, the Department shall, by July 1, 2016, test the
759	759	8 viability of the new system and implement any necessary
760	760	9 operational or structural changes to its information
761	761	10 technology platforms in order to allow for the direct
762	762	11 acceptance and payment of nursing home claims.
763	763	12 Notwithstanding any other law to the contrary, the
764	764	13 Illinois Department shall, within 365 days after August 15,
765	765	14 2014 (the effective date of Public Act 98-963), establish
766	766	15 procedures to permit ID/DD facilities licensed under the ID/DD
767	767	16 Community Care Act and MC/DD facilities licensed under the
768	768	17 MC/DD Act to submit monthly billing claims for reimbursement
769	769	18 purposes. Following development of these procedures, the
770	770	19 Department shall have an additional 365 days to test the
771	771	20 viability of the new system and to ensure that any necessary
772	772	21 operational or structural changes to its information
773	773	22 technology platforms are implemented.
774	774	23 The Illinois Department shall require all dispensers of
775	775	24 medical services, other than an individual practitioner or
776	776	25 group of practitioners, desiring to participate in the Medical
777	777	26 Assistance program established under this Article to disclose
778	778
779	779
780	780
781	781
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784	784
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788	788	1 all financial, beneficial, ownership, equity, surety or other
789	789	2 interests in any and all firms, corporations, partnerships,
790	790	3 associations, business enterprises, joint ventures, agencies,
791	791	4 institutions or other legal entities providing any form of
792	792	5 health care services in this State under this Article.
793	793	6 The Illinois Department may require that all dispensers of
794	794	7 medical services desiring to participate in the medical
795	795	8 assistance program established under this Article disclose,
796	796	9 under such terms and conditions as the Illinois Department may
797	797	10 by rule establish, all inquiries from clients and attorneys
798	798	11 regarding medical bills paid by the Illinois Department, which
799	799	12 inquiries could indicate potential existence of claims or
800	800	13 liens for the Illinois Department.
801	801	14 Enrollment of a vendor shall be subject to a provisional
802	802	15 period and shall be conditional for one year. During the
803	803	16 period of conditional enrollment, the Department may terminate
804	804	17 the vendor's eligibility to participate in, or may disenroll
805	805	18 the vendor from, the medical assistance program without cause.
806	806	19 Unless otherwise specified, such termination of eligibility or
807	807	20 disenrollment is not subject to the Department's hearing
808	808	21 process. However, a disenrolled vendor may reapply without
809	809	22 penalty.
810	810	23 The Department has the discretion to limit the conditional
811	811	24 enrollment period for vendors based upon the category of risk
812	812	25 of the vendor.
813	813	26 Prior to enrollment and during the conditional enrollment
814	814
815	815
816	816
817	817
818	818
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820	820
821	821
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824	824	1 period in the medical assistance program, all vendors shall be
825	825	2 subject to enhanced oversight, screening, and review based on
826	826	3 the risk of fraud, waste, and abuse that is posed by the
827	827	4 category of risk of the vendor. The Illinois Department shall
828	828	5 establish the procedures for oversight, screening, and review,
829	829	6 which may include, but need not be limited to: criminal and
830	830	7 financial background checks; fingerprinting; license,
831	831	8 certification, and authorization verifications; unscheduled or
832	832	9 unannounced site visits; database checks; prepayment audit
833	833	10 reviews; audits; payment caps; payment suspensions; and other
834	834	11 screening as required by federal or State law.
835	835	12 The Department shall define or specify the following: (i)
836	836	13 by provider notice, the "category of risk of the vendor" for
837	837	14 each type of vendor, which shall take into account the level of
838	838	15 screening applicable to a particular category of vendor under
839	839	16 federal law and regulations; (ii) by rule or provider notice,
840	840	17 the maximum length of the conditional enrollment period for
841	841	18 each category of risk of the vendor; and (iii) by rule, the
842	842	19 hearing rights, if any, afforded to a vendor in each category
843	843	20 of risk of the vendor that is terminated or disenrolled during
844	844	21 the conditional enrollment period.
845	845	22 To be eligible for payment consideration, a vendor's
846	846	23 payment claim or bill, either as an initial claim or as a
847	847	24 resubmitted claim following prior rejection, must be received
848	848	25 by the Illinois Department, or its fiscal intermediary, no
849	849	26 later than 180 days after the latest date on the claim on which
850	850
851	851
852	852
853	853
854	854
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856	856
857	857
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859	859	HB2554 - 24 - LRB104 06104 KTG 16137 b
860	860	1 medical goods or services were provided, with the following
861	861	2 exceptions:
862	862	3 (1) In the case of a provider whose enrollment is in
863	863	4 process by the Illinois Department, the 180-day period
864	864	5 shall not begin until the date on the written notice from
865	865	6 the Illinois Department that the provider enrollment is
866	866	7 complete.
867	867	8 (2) In the case of errors attributable to the Illinois
868	868	9 Department or any of its claims processing intermediaries
869	869	10 which result in an inability to receive, process, or
870	870	11 adjudicate a claim, the 180-day period shall not begin
871	871	12 until the provider has been notified of the error.
872	872	13 (3) In the case of a provider for whom the Illinois
873	873	14 Department initiates the monthly billing process.
874	874	15 (4) In the case of a provider operated by a unit of
875	875	16 local government with a population exceeding 3,000,000
876	876	17 when local government funds finance federal participation
877	877	18 for claims payments.
878	878	19 For claims for services rendered during a period for which
879	879	20 a recipient received retroactive eligibility, claims must be
880	880	21 filed within 180 days after the Department determines the
881	881	22 applicant is eligible. For claims for which the Illinois
882	882	23 Department is not the primary payer, claims must be submitted
883	883	24 to the Illinois Department within 180 days after the final
884	884	25 adjudication by the primary payer.
885	885	26 In the case of long term care facilities, within 120
886	886
887	887
888	888
889	889
890	890
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892	892
893	893
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895	895	HB2554 - 25 - LRB104 06104 KTG 16137 b
896	896	1 calendar days of receipt by the facility of required
897	897	2 prescreening information, new admissions with associated
898	898	3 admission documents shall be submitted through the Medical
899	899	4 Electronic Data Interchange (MEDI) or the Recipient
900	900	5 Eligibility Verification (REV) System or shall be submitted
901	901	6 directly to the Department of Human Services using required
902	902	7 admission forms. Effective September 1, 2014, admission
903	903	8 documents, including all prescreening information, must be
904	904	9 submitted through MEDI or REV. Confirmation numbers assigned
905	905	10 to an accepted transaction shall be retained by a facility to
906	906	11 verify timely submittal. Once an admission transaction has
907	907	12 been completed, all resubmitted claims following prior
908	908	13 rejection are subject to receipt no later than 180 days after
909	909	14 the admission transaction has been completed.
910	910	15 Claims that are not submitted and received in compliance
911	911	16 with the foregoing requirements shall not be eligible for
912	912	17 payment under the medical assistance program, and the State
913	913	18 shall have no liability for payment of those claims.
914	914	19 To the extent consistent with applicable information and
915	915	20 privacy, security, and disclosure laws, State and federal
916	916	21 agencies and departments shall provide the Illinois Department
917	917	22 access to confidential and other information and data
918	918	23 necessary to perform eligibility and payment verifications and
919	919	24 other Illinois Department functions. This includes, but is not
920	920	25 limited to: information pertaining to licensure;
921	921	26 certification; earnings; immigration status; citizenship; wage
922	922
923	923
924	924
925	925
926	926
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928	928
929	929
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932	932	1 reporting; unearned and earned income; pension income;
933	933	2 employment; supplemental security income; social security
934	934	3 numbers; National Provider Identifier (NPI) numbers; the
935	935	4 National Practitioner Data Bank (NPDB); program and agency
936	936	5 exclusions; taxpayer identification numbers; tax delinquency;
937	937	6 corporate information; and death records.
938	938	7 The Illinois Department shall enter into agreements with
939	939	8 State agencies and departments, and is authorized to enter
940	940	9 into agreements with federal agencies and departments, under
941	941	10 which such agencies and departments shall share data necessary
942	942	11 for medical assistance program integrity functions and
943	943	12 oversight. The Illinois Department shall develop, in
944	944	13 cooperation with other State departments and agencies, and in
945	945	14 compliance with applicable federal laws and regulations,
946	946	15 appropriate and effective methods to share such data. At a
947	947	16 minimum, and to the extent necessary to provide data sharing,
948	948	17 the Illinois Department shall enter into agreements with State
949	949	18 agencies and departments, and is authorized to enter into
950	950	19 agreements with federal agencies and departments, including,
951	951	20 but not limited to: the Secretary of State; the Department of
952	952	21 Revenue; the Department of Public Health; the Department of
953	953	22 Human Services; and the Department of Financial and
954	954	23 Professional Regulation.
955	955	24 Beginning in fiscal year 2013, the Illinois Department
956	956	25 shall set forth a request for information to identify the
957	957	26 benefits of a pre-payment, post-adjudication, and post-edit
958	958
959	959
960	960
961	961
962	962
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964	964
965	965
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968	968	1 claims system with the goals of streamlining claims processing
969	969	2 and provider reimbursement, reducing the number of pending or
970	970	3 rejected claims, and helping to ensure a more transparent
971	971	4 adjudication process through the utilization of: (i) provider
972	972	5 data verification and provider screening technology; and (ii)
973	973	6 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
974	974	7 post-adjudicated predictive modeling with an integrated case
975	975	8 management system with link analysis. Such a request for
976	976	9 information shall not be considered as a request for proposal
977	977	10 or as an obligation on the part of the Illinois Department to
978	978	11 take any action or acquire any products or services.
979	979	12 The Illinois Department shall establish policies,
980	980	13 procedures, standards and criteria by rule for the
981	981	14 acquisition, repair and replacement of orthotic and prosthetic
982	982	15 devices and durable medical equipment. Such rules shall
983	983	16 provide, but not be limited to, the following services: (1)
984	984	17 immediate repair or replacement of such devices by recipients;
985	985	18 and (2) rental, lease, purchase or lease-purchase of durable
986	986	19 medical equipment in a cost-effective manner, taking into
987	987	20 consideration the recipient's medical prognosis, the extent of
988	988	21 the recipient's needs, and the requirements and costs for
989	989	22 maintaining such equipment. Subject to prior approval, such
990	990	23 rules shall enable a recipient to temporarily acquire and use
991	991	24 alternative or substitute devices or equipment pending repairs
992	992	25 or replacements of any device or equipment previously
993	993	26 authorized for such recipient by the Department.
994	994
995	995
996	996
997	997
998	998
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1000	1000
1001	1001
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1004	1004	1 Notwithstanding any provision of Section 5-5f to the contrary,
1005	1005	2 the Department may, by rule, exempt certain replacement
1006	1006	3 wheelchair parts from prior approval and, for wheelchairs,
1007	1007	4 wheelchair parts, wheelchair accessories, and related seating
1008	1008	5 and positioning items, determine the wholesale price by
1009	1009	6 methods other than actual acquisition costs.
1010	1010	7 The Department shall require, by rule, all providers of
1011	1011	8 durable medical equipment to be accredited by an accreditation
1012	1012	9 organization approved by the federal Centers for Medicare and
1013	1013	10 Medicaid Services and recognized by the Department in order to
1014	1014	11 bill the Department for providing durable medical equipment to
1015	1015	12 recipients. No later than 15 months after the effective date
1016	1016	13 of the rule adopted pursuant to this paragraph, all providers
1017	1017	14 must meet the accreditation requirement.
1018	1018	15 In order to promote environmental responsibility, meet the
1019	1019	16 needs of recipients and enrollees, and achieve significant
1020	1020	17 cost savings, the Department, or a managed care organization
1021	1021	18 under contract with the Department, may provide recipients or
1022	1022	19 managed care enrollees who have a prescription or Certificate
1023	1023	20 of Medical Necessity access to refurbished durable medical
1024	1024	21 equipment under this Section (excluding prosthetic and
1025	1025	22 orthotic devices as defined in the Orthotics, Prosthetics, and
1026	1026	23 Pedorthics Practice Act and complex rehabilitation technology
1027	1027	24 products and associated services) through the State's
1028	1028	25 assistive technology program's reutilization program, using
1029	1029	26 staff with the Assistive Technology Professional (ATP)
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB2554 - 28 - LRB104 06104 KTG 16137 b
1036	1036
1037	1037
1038	1038	HB2554- 29 -LRB104 06104 KTG 16137 b HB2554 - 29 - LRB104 06104 KTG 16137 b
1039	1039	HB2554 - 29 - LRB104 06104 KTG 16137 b
1040	1040	1 Certification if the refurbished durable medical equipment:
1041	1041	2 (i) is available; (ii) is less expensive, including shipping
1042	1042	3 costs, than new durable medical equipment of the same type;
1043	1043	4 (iii) is able to withstand at least 3 years of use; (iv) is
1044	1044	5 cleaned, disinfected, sterilized, and safe in accordance with
1045	1045	6 federal Food and Drug Administration regulations and guidance
1046	1046	7 governing the reprocessing of medical devices in health care
1047	1047	8 settings; and (v) equally meets the needs of the recipient or
1048	1048	9 enrollee. The reutilization program shall confirm that the
1049	1049	10 recipient or enrollee is not already in receipt of the same or
1050	1050	11 similar equipment from another service provider, and that the
1051	1051	12 refurbished durable medical equipment equally meets the needs
1052	1052	13 of the recipient or enrollee. Nothing in this paragraph shall
1053	1053	14 be construed to limit recipient or enrollee choice to obtain
1054	1054	15 new durable medical equipment or place any additional prior
1055	1055	16 authorization conditions on enrollees of managed care
1056	1056	17 organizations.
1057	1057	18 The Department shall execute, relative to the nursing home
1058	1058	19 prescreening project, written inter-agency agreements with the
1059	1059	20 Department of Human Services and the Department on Aging, to
1060	1060	21 effect the following: (i) intake procedures and common
1061	1061	22 eligibility criteria for those persons who are receiving
1062	1062	23 non-institutional services; and (ii) the establishment and
1063	1063	24 development of non-institutional services in areas of the
1064	1064	25 State where they are not currently available or are
1065	1065	26 undeveloped; and (iii) notwithstanding any other provision of
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070
1071	1071	HB2554 - 29 - LRB104 06104 KTG 16137 b
1072	1072
1073	1073
1074	1074	HB2554- 30 -LRB104 06104 KTG 16137 b HB2554 - 30 - LRB104 06104 KTG 16137 b
1075	1075	HB2554 - 30 - LRB104 06104 KTG 16137 b
1076	1076	1 law, subject to federal approval, on and after July 1, 2012, an
1077	1077	2 increase in the determination of need (DON) scores from 29 to
1078	1078	3 37 for applicants for institutional and home and
1079	1079	4 community-based long term care; if and only if federal
1080	1080	5 approval is not granted, the Department may, in conjunction
1081	1081	6 with other affected agencies, implement utilization controls
1082	1082	7 or changes in benefit packages to effectuate a similar savings
1083	1083	8 amount for this population; and (iv) no later than July 1,
1084	1084	9 2013, minimum level of care eligibility criteria for
1085	1085	10 institutional and home and community-based long term care; and
1086	1086	11 (v) no later than October 1, 2013, establish procedures to
1087	1087	12 permit long term care providers access to eligibility scores
1088	1088	13 for individuals with an admission date who are seeking or
1089	1089	14 receiving services from the long term care provider. In order
1090	1090	15 to select the minimum level of care eligibility criteria, the
1091	1091	16 Governor shall establish a workgroup that includes affected
1092	1092	17 agency representatives and stakeholders representing the
1093	1093	18 institutional and home and community-based long term care
1094	1094	19 interests. This Section shall not restrict the Department from
1095	1095	20 implementing lower level of care eligibility criteria for
1096	1096	21 community-based services in circumstances where federal
1097	1097	22 approval has been granted.
1098	1098	23 The Illinois Department shall develop and operate, in
1099	1099	24 cooperation with other State Departments and agencies and in
1100	1100	25 compliance with applicable federal laws and regulations,
1101	1101	26 appropriate and effective systems of health care evaluation
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106
1107	1107	HB2554 - 30 - LRB104 06104 KTG 16137 b
1108	1108
1109	1109
1110	1110	HB2554- 31 -LRB104 06104 KTG 16137 b HB2554 - 31 - LRB104 06104 KTG 16137 b
1111	1111	HB2554 - 31 - LRB104 06104 KTG 16137 b
1112	1112	1 and programs for monitoring of utilization of health care
1113	1113	2 services and facilities, as it affects persons eligible for
1114	1114	3 medical assistance under this Code.
1115	1115	4 The Illinois Department shall report annually to the
1116	1116	5 General Assembly, no later than the second Friday in April of
1117	1117	6 1979 and each year thereafter, in regard to:
1118	1118	7 (a) actual statistics and trends in utilization of
1119	1119	8 medical services by public aid recipients;
1120	1120	9 (b) actual statistics and trends in the provision of
1121	1121	10 the various medical services by medical vendors;
1122	1122	11 (c) current rate structures and proposed changes in
1123	1123	12 those rate structures for the various medical vendors; and
1124	1124	13 (d) efforts at utilization review and control by the
1125	1125	14 Illinois Department.
1126	1126	15 The period covered by each report shall be the 3 years
1127	1127	16 ending on the June 30 prior to the report. The report shall
1128	1128	17 include suggested legislation for consideration by the General
1129	1129	18 Assembly. The requirement for reporting to the General
1130	1130	19 Assembly shall be satisfied by filing copies of the report as
1131	1131	20 required by Section 3.1 of the General Assembly Organization
1132	1132	21 Act, and filing such additional copies with the State
1133	1133	22 Government Report Distribution Center for the General Assembly
1134	1134	23 as is required under paragraph (t) of Section 7 of the State
1135	1135	24 Library Act.
1136	1136	25 Rulemaking authority to implement Public Act 95-1045, if
1137	1137	26 any, is conditioned on the rules being adopted in accordance
1138	1138
1139	1139
1140	1140
1141	1141
1142	1142
1143	1143	HB2554 - 31 - LRB104 06104 KTG 16137 b
1144	1144
1145	1145
1146	1146	HB2554- 32 -LRB104 06104 KTG 16137 b HB2554 - 32 - LRB104 06104 KTG 16137 b
1147	1147	HB2554 - 32 - LRB104 06104 KTG 16137 b
1148	1148	1 with all provisions of the Illinois Administrative Procedure
1149	1149	2 Act and all rules and procedures of the Joint Committee on
1150	1150	3 Administrative Rules; any purported rule not so adopted, for
1151	1151	4 whatever reason, is unauthorized.
1152	1152	5 On and after July 1, 2012, the Department shall reduce any
1153	1153	6 rate of reimbursement for services or other payments or alter
1154	1154	7 any methodologies authorized by this Code to reduce any rate
1155	1155	8 of reimbursement for services or other payments in accordance
1156	1156	9 with Section 5-5e.
1157	1157	10 Because kidney transplantation can be an appropriate,
1158	1158	11 cost-effective alternative to renal dialysis when medically
1159	1159	12 necessary and notwithstanding the provisions of Section 1-11
1160	1160	13 of this Code, beginning October 1, 2014, the Department shall
1161	1161	14 cover kidney transplantation for noncitizens with end-stage
1162	1162	15 renal disease who are not eligible for comprehensive medical
1163	1163	16 benefits, who meet the residency requirements of Section 5-3
1164	1164	17 of this Code, and who would otherwise meet the financial
1165	1165	18 requirements of the appropriate class of eligible persons
1166	1166	19 under Section 5-2 of this Code. To qualify for coverage of
1167	1167	20 kidney transplantation, such person must be receiving
1168	1168	21 emergency renal dialysis services covered by the Department.
1169	1169	22 Providers under this Section shall be prior approved and
1170	1170	23 certified by the Department to perform kidney transplantation
1171	1171	24 and the services under this Section shall be limited to
1172	1172	25 services associated with kidney transplantation.
1173	1173	26 Notwithstanding any other provision of this Code to the
1174	1174
1175	1175
1176	1176
1177	1177
1178	1178
1179	1179	HB2554 - 32 - LRB104 06104 KTG 16137 b
1180	1180
1181	1181
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1183	1183	HB2554 - 33 - LRB104 06104 KTG 16137 b
1184	1184	1 contrary, on or after July 1, 2015, all FDA-approved FDA
1185	1185	2 approved forms of medication assisted treatment prescribed for
1186	1186	3 the treatment of alcohol dependence or treatment of opioid
1187	1187	4 dependence shall be covered under both fee-for-service and
1188	1188	5 managed care medical assistance programs for persons who are
1189	1189	6 otherwise eligible for medical assistance under this Article
1190	1190	7 and shall not be subject to any (1) utilization control, other
1191	1191	8 than those established under the American Society of Addiction
1192	1192	9 Medicine patient placement criteria, (2) prior authorization
1193	1193	10 mandate, (3) lifetime restriction limit mandate, or (4)
1194	1194	11 limitations on dosage.
1195	1195	12 On or after July 1, 2015, opioid antagonists prescribed
1196	1196	13 for the treatment of an opioid overdose, including the
1197	1197	14 medication product, administration devices, and any pharmacy
1198	1198	15 fees or hospital fees related to the dispensing, distribution,
1199	1199	16 and administration of the opioid antagonist, shall be covered
1200	1200	17 under the medical assistance program for persons who are
1201	1201	18 otherwise eligible for medical assistance under this Article.
1202	1202	19 As used in this Section, "opioid antagonist" means a drug that
1203	1203	20 binds to opioid receptors and blocks or inhibits the effect of
1204	1204	21 opioids acting on those receptors, including, but not limited
1205	1205	22 to, naloxone hydrochloride or any other similarly acting drug
1206	1206	23 approved by the U.S. Food and Drug Administration. The
1207	1207	24 Department shall not impose a copayment on the coverage
1208	1208	25 provided for naloxone hydrochloride under the medical
1209	1209	26 assistance program.
1210	1210
1211	1211
1212	1212
1213	1213
1214	1214
1215	1215	HB2554 - 33 - LRB104 06104 KTG 16137 b
1216	1216
1217	1217
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1219	1219	HB2554 - 34 - LRB104 06104 KTG 16137 b
1220	1220	1 Upon federal approval, the Department shall provide
1221	1221	2 coverage and reimbursement for all drugs that are approved for
1222	1222	3 marketing by the federal Food and Drug Administration and that
1223	1223	4 are recommended by the federal Public Health Service or the
1224	1224	5 United States Centers for Disease Control and Prevention for
1225	1225	6 pre-exposure prophylaxis and related pre-exposure prophylaxis
1226	1226	7 services, including, but not limited to, HIV and sexually
1227	1227	8 transmitted infection screening, treatment for sexually
1228	1228	9 transmitted infections, medical monitoring, assorted labs, and
1229	1229	10 counseling to reduce the likelihood of HIV infection among
1230	1230	11 individuals who are not infected with HIV but who are at high
1231	1231	12 risk of HIV infection.
1232	1232	13 A federally qualified health center, as defined in Section
1233	1233	14 1905(l)(2)(B) of the federal Social Security Act, shall be
1234	1234	15 reimbursed by the Department in accordance with the federally
1235	1235	16 qualified health center's encounter rate for services provided
1236	1236	17 to medical assistance recipients that are performed by a
1237	1237	18 dental hygienist, as defined under the Illinois Dental
1238	1238	19 Practice Act, working under the general supervision of a
1239	1239	20 dentist and employed by a federally qualified health center.
1240	1240	21 Within 90 days after October 8, 2021 (the effective date
1241	1241	22 of Public Act 102-665), the Department shall seek federal
1242	1242	23 approval of a State Plan amendment to expand coverage for
1243	1243	24 family planning services that includes presumptive eligibility
1244	1244	25 to individuals whose income is at or below 208% of the federal
1245	1245	26 poverty level. Coverage under this Section shall be effective
1246	1246
1247	1247
1248	1248
1249	1249
1250	1250
1251	1251	HB2554 - 34 - LRB104 06104 KTG 16137 b
1252	1252
1253	1253
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1255	1255	HB2554 - 35 - LRB104 06104 KTG 16137 b
1256	1256	1 beginning no later than December 1, 2022.
1257	1257	2 Subject to approval by the federal Centers for Medicare
1258	1258	3 and Medicaid Services of a Title XIX State Plan amendment
1259	1259	4 electing the Program of All-Inclusive Care for the Elderly
1260	1260	5 (PACE) as a State Medicaid option, as provided for by Subtitle
1261	1261	6 I (commencing with Section 4801) of Title IV of the Balanced
1262	1262	7 Budget Act of 1997 (Public Law 105-33) and Part 460
1263	1263	8 (commencing with Section 460.2) of Subchapter E of Title 42 of
1264	1264	9 the Code of Federal Regulations, PACE program services shall
1265	1265	10 become a covered benefit of the medical assistance program,
1266	1266	11 subject to criteria established in accordance with all
1267	1267	12 applicable laws.
1268	1268	13 Notwithstanding any other provision of this Code,
1269	1269	14 community-based pediatric palliative care from a trained
1270	1270	15 interdisciplinary team shall be covered under the medical
1271	1271	16 assistance program as provided in Section 15 of the Pediatric
1272	1272	17 Palliative Care Act.
1273	1273	18 Notwithstanding any other provision of this Code, within
1274	1274	19 12 months after June 2, 2022 (the effective date of Public Act
1275	1275	20 102-1037) and subject to federal approval, acupuncture
1276	1276	21 services performed by an acupuncturist licensed under the
1277	1277	22 Acupuncture Practice Act who is acting within the scope of his
1278	1278	23 or her license shall be covered under the medical assistance
1279	1279	24 program. The Department shall apply for any federal waiver or
1280	1280	25 State Plan amendment, if required, to implement this
1281	1281	26 paragraph. The Department may adopt any rules, including
1282	1282
1283	1283
1284	1284
1285	1285
1286	1286
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1288	1288
1289	1289
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1291	1291	HB2554 - 36 - LRB104 06104 KTG 16137 b
1292	1292	1 standards and criteria, necessary to implement this paragraph.
1293	1293	2 Notwithstanding any other provision of this Code, the
1294	1294	3 medical assistance program shall, subject to federal approval,
1295	1295	4 reimburse hospitals for costs associated with a newborn
1296	1296	5 screening test for the presence of metachromatic
1297	1297	6 leukodystrophy, as required under the Newborn Metabolic
1298	1298	7 Screening Act, at a rate not less than the fee charged by the
1299	1299	8 Department of Public Health. Notwithstanding any other
1300	1300	9 provision of this Code, the medical assistance program shall,
1301	1301	10 subject to appropriation and federal approval, also reimburse
1302	1302	11 hospitals for costs associated with all newborn screening
1303	1303	12 tests added on and after August 9, 2024 (the effective date of
1304	1304	13 Public Act 103-909) this amendatory Act of the 103rd General
1305	1305	14 Assembly to the Newborn Metabolic Screening Act and required
1306	1306	15 to be performed under that Act at a rate not less than the fee
1307	1307	16 charged by the Department of Public Health. The Department
1308	1308	17 shall seek federal approval before the implementation of the
1309	1309	18 newborn screening test fees by the Department of Public
1310	1310	19 Health.
1311	1311	20 Notwithstanding any other provision of this Code,
1312	1312	21 beginning on January 1, 2024, subject to federal approval,
1313	1313	22 cognitive assessment and care planning services provided to a
1314	1314	23 person who experiences signs or symptoms of cognitive
1315	1315	24 impairment, as defined by the Diagnostic and Statistical
1316	1316	25 Manual of Mental Disorders, Fifth Edition, shall be covered
1317	1317	26 under the medical assistance program for persons who are
1318	1318
1319	1319
1320	1320
1321	1321
1322	1322
1323	1323	HB2554 - 36 - LRB104 06104 KTG 16137 b
1324	1324
1325	1325
1326	1326	HB2554- 37 -LRB104 06104 KTG 16137 b HB2554 - 37 - LRB104 06104 KTG 16137 b
1327	1327	HB2554 - 37 - LRB104 06104 KTG 16137 b
1328	1328	1 otherwise eligible for medical assistance under this Article.
1329	1329	2 Notwithstanding any other provision of this Code,
1330	1330	3 medically necessary reconstructive services that are intended
1331	1331	4 to restore physical appearance shall be covered under the
1332	1332	5 medical assistance program for persons who are otherwise
1333	1333	6 eligible for medical assistance under this Article. As used in
1334	1334	7 this paragraph, "reconstructive services" means treatments
1335	1335	8 performed on structures of the body damaged by trauma to
1336	1336	9 restore physical appearance.
1337	1337	10 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1338	1338	11 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1339	1339	12 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1340	1340	13 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1341	1341	14 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1342	1342	15 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1343	1343	16 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1344	1344	17 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1345	1345	18 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1346	1346	19 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
1347	1347	20 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
1348	1348	21 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
1349	1349	22 8-9-24; revised 10-10-24.)
1350	1350
1351	1351
1352	1352
1353	1353
1354	1354
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