HB4180 EnrolledLRB103 34255 MXP 64081 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Counties Code is amended by changing
5Section 5-1069 as follows:
 
6    (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
7    Sec. 5-1069. Group life, health, accident, hospital, and
8medical insurance.
9    (a) The county board of any county may arrange to provide,
10for the benefit of employees of the county, group life,
11health, accident, hospital, and medical insurance, or any one
12or any combination of those types of insurance, or the county
13board may self-insure, for the benefit of its employees, all
14or a portion of the employees' group life, health, accident,
15hospital, and medical insurance, or any one or any combination
16of those types of insurance, including a combination of
17self-insurance and other types of insurance authorized by this
18Section, provided that the county board complies with all
19other requirements of this Section. The insurance may include
20provision for employees who rely on treatment by prayer or
21spiritual means alone for healing in accordance with the
22tenets and practice of a well recognized religious
23denomination. The county board may provide for payment by the

 

 

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1county of a portion or all of the premium or charge for the
2insurance with the employee paying the balance of the premium
3or charge, if any. If the county board undertakes a plan under
4which the county pays only a portion of the premium or charge,
5the county board shall provide for withholding and deducting
6from the compensation of those employees who consent to join
7the plan the balance of the premium or charge for the
8insurance.
9    (b) If the county board does not provide for
10self-insurance or for a plan under which the county pays a
11portion or all of the premium or charge for a group insurance
12plan, the county board may provide for withholding and
13deducting from the compensation of those employees who consent
14thereto the total premium or charge for any group life,
15health, accident, hospital, and medical insurance.
16    (c) The county board may exercise the powers granted in
17this Section only if it provides for self-insurance or, where
18it makes arrangements to provide group insurance through an
19insurance carrier, if the kinds of group insurance are
20obtained from an insurance company authorized to do business
21in the State of Illinois. The county board may enact an
22ordinance prescribing the method of operation of the insurance
23program.
24    (d) If a county, including a home rule county, is a
25self-insurer for purposes of providing health insurance
26coverage for its employees, the insurance coverage shall

 

 

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1include screening by low-dose mammography for all patients
2women 35 years of age or older for the presence of occult
3breast cancer unless the county elects to provide mammograms
4itself under Section 5-1069.1. The coverage shall be as
5follows:
6        (1) A baseline mammogram for patients women 35 to 39
7    years of age.
8        (2) An annual mammogram for patients women 40 years of
9    age or older.
10        (3) A mammogram at the age and intervals considered
11    medically necessary by the patient's woman's health care
12    provider for patients women under 40 years of age and
13    having a family history of breast cancer, prior personal
14    history of breast cancer, positive genetic testing, or
15    other risk factors.
16        (4) For a group policy of accident and health
17    insurance that is amended, delivered, issued, or renewed
18    on or after January 1, 2020 (the effective date of Public
19    Act 101-580) this amendatory Act of the 101st General
20    Assembly, a comprehensive ultrasound screening of an
21    entire breast or breasts if a mammogram demonstrates
22    heterogeneous or dense breast tissue or when medically
23    necessary as determined by a physician licensed to
24    practice medicine in all of its branches, advanced
25    practice registered nurse, or physician assistant.
26        (4.5) For a group policy of accident and health

 

 

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1    insurance that is amended, delivered, issued, or renewed
2    on or after the effective date of this amendatory Act of
3    the 103rd General Assembly, molecular breast imaging (MBI)
4    and magnetic resonance imaging of an entire breast or
5    breasts if a mammogram demonstrates heterogeneous or dense
6    breast tissue or when medically necessary as determined by
7    a physician licensed to practice medicine in all of its
8    branches, advanced practice registered nurse, or physician
9    assistant.
10        (5) For a group policy of accident and health
11    insurance that is amended, delivered, issued, or renewed
12    on or after January 1, 2020 (the effective date of Public
13    Act 101-580) this amendatory Act of the 101st General
14    Assembly, a diagnostic mammogram when medically necessary,
15    as determined by a physician licensed to practice medicine
16    in all its branches, advanced practice registered nurse,
17    or physician assistant.
18    A policy subject to this subsection shall not impose a
19deductible, coinsurance, copayment, or any other cost-sharing
20requirement on the coverage provided; except that this
21sentence does not apply to coverage of diagnostic mammograms
22to the extent such coverage would disqualify a high-deductible
23health plan from eligibility for a health savings account
24pursuant to Section 223 of the Internal Revenue Code (26
25U.S.C. 223).
26    For purposes of this subsection:

 

 

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1    "Diagnostic mammogram" means a mammogram obtained using
2diagnostic mammography.
3    "Diagnostic mammography" means a method of screening that
4is designed to evaluate an abnormality in a breast, including
5an abnormality seen or suspected on a screening mammogram or a
6subjective or objective abnormality otherwise detected in the
7breast.
8    "Low-dose mammography" means the x-ray examination of the
9breast using equipment dedicated specifically for mammography,
10including the x-ray tube, filter, compression device, and
11image receptor, with an average radiation exposure delivery of
12less than one rad per breast for 2 views of an average size
13breast. The term also includes digital mammography.
14    (d-5) Coverage as described by subsection (d) shall be
15provided at no cost to the insured and shall not be applied to
16an annual or lifetime maximum benefit.
17    (d-10) When health care services are available through
18contracted providers and a person does not comply with plan
19provisions specific to the use of contracted providers, the
20requirements of subsection (d-5) are not applicable. When a
21person does not comply with plan provisions specific to the
22use of contracted providers, plan provisions specific to the
23use of non-contracted providers must be applied without
24distinction for coverage required by this Section and shall be
25at least as favorable as for other radiological examinations
26covered by the policy or contract.

 

 

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1    (d-15) If a county, including a home rule county, is a
2self-insurer for purposes of providing health insurance
3coverage for its employees, the insurance coverage shall
4include mastectomy coverage, which includes coverage for
5prosthetic devices or reconstructive surgery incident to the
6mastectomy. Coverage for breast reconstruction in connection
7with a mastectomy shall include:
8        (1) reconstruction of the breast upon which the
9    mastectomy has been performed;
10        (2) surgery and reconstruction of the other breast to
11    produce a symmetrical appearance; and
12        (3) prostheses and treatment for physical
13    complications at all stages of mastectomy, including
14    lymphedemas.
15Care shall be determined in consultation with the attending
16physician and the patient. The offered coverage for prosthetic
17devices and reconstructive surgery shall be subject to the
18deductible and coinsurance conditions applied to the
19mastectomy, and all other terms and conditions applicable to
20other benefits. When a mastectomy is performed and there is no
21evidence of malignancy then the offered coverage may be
22limited to the provision of prosthetic devices and
23reconstructive surgery to within 2 years after the date of the
24mastectomy. As used in this Section, "mastectomy" means the
25removal of all or part of the breast for medically necessary
26reasons, as determined by a licensed physician.

 

 

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1    A county, including a home rule county, that is a
2self-insurer for purposes of providing health insurance
3coverage for its employees, may not penalize or reduce or
4limit the reimbursement of an attending provider or provide
5incentives (monetary or otherwise) to an attending provider to
6induce the provider to provide care to an insured in a manner
7inconsistent with this Section.
8    (d-20) The requirement that mammograms be included in
9health insurance coverage as provided in subsections (d)
10through (d-15) is an exclusive power and function of the State
11and is a denial and limitation under Article VII, Section 6,
12subsection (h) of the Illinois Constitution of home rule
13county powers. A home rule county to which subsections (d)
14through (d-15) apply must comply with every provision of those
15subsections.
16    (e) The term "employees" as used in this Section includes
17elected or appointed officials but does not include temporary
18employees.
19    (f) The county board may, by ordinance, arrange to provide
20group life, health, accident, hospital, and medical insurance,
21or any one or a combination of those types of insurance, under
22this Section to retired former employees and retired former
23elected or appointed officials of the county.
24    (g) Rulemaking authority to implement this amendatory Act
25of the 95th General Assembly, if any, is conditioned on the
26rules being adopted in accordance with all provisions of the

 

 

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1Illinois Administrative Procedure Act and all rules and
2procedures of the Joint Committee on Administrative Rules; any
3purported rule not so adopted, for whatever reason, is
4unauthorized.
5(Source: P.A. 100-513, eff. 1-1-18; 101-580, eff. 1-1-20.)
 
6    Section 10. The Illinois Municipal Code is amended by
7changing Section 10-4-2 as follows:
 
8    (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
9    Sec. 10-4-2. Group insurance.
10    (a) The corporate authorities of any municipality may
11arrange to provide, for the benefit of employees of the
12municipality, group life, health, accident, hospital, and
13medical insurance, or any one or any combination of those
14types of insurance, and may arrange to provide that insurance
15for the benefit of the spouses or dependents of those
16employees. The insurance may include provision for employees
17or other insured persons who rely on treatment by prayer or
18spiritual means alone for healing in accordance with the
19tenets and practice of a well recognized religious
20denomination. The corporate authorities may provide for
21payment by the municipality of a portion of the premium or
22charge for the insurance with the employee paying the balance
23of the premium or charge. If the corporate authorities
24undertake a plan under which the municipality pays a portion

 

 

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1of the premium or charge, the corporate authorities shall
2provide for withholding and deducting from the compensation of
3those municipal employees who consent to join the plan the
4balance of the premium or charge for the insurance.
5    (b) If the corporate authorities do not provide for a plan
6under which the municipality pays a portion of the premium or
7charge for a group insurance plan, the corporate authorities
8may provide for withholding and deducting from the
9compensation of those employees who consent thereto the
10premium or charge for any group life, health, accident,
11hospital, and medical insurance.
12    (c) The corporate authorities may exercise the powers
13granted in this Section only if the kinds of group insurance
14are obtained from an insurance company authorized to do
15business in the State of Illinois, or are obtained through an
16intergovernmental joint self-insurance pool as authorized
17under the Intergovernmental Cooperation Act. The corporate
18authorities may enact an ordinance prescribing the method of
19operation of the insurance program.
20    (d) If a municipality, including a home rule municipality,
21is a self-insurer for purposes of providing health insurance
22coverage for its employees, the insurance coverage shall
23include screening by low-dose mammography for all patients
24women 35 years of age or older for the presence of occult
25breast cancer unless the municipality elects to provide
26mammograms itself under Section 10-4-2.1. The coverage shall

 

 

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1be as follows:
2        (1) A baseline mammogram for patients women 35 to 39
3    years of age.
4        (2) An annual mammogram for patients women 40 years of
5    age or older.
6        (3) A mammogram at the age and intervals considered
7    medically necessary by the patient's woman's health care
8    provider for patients women under 40 years of age and
9    having a family history of breast cancer, prior personal
10    history of breast cancer, positive genetic testing, or
11    other risk factors.
12        (4) For a group policy of accident and health
13    insurance that is amended, delivered, issued, or renewed
14    on or after January 1, 2020 (the effective date of Public
15    Act 101-580) this amendatory Act of the 101st General
16    Assembly, a comprehensive ultrasound screening of an
17    entire breast or breasts if a mammogram demonstrates
18    heterogeneous or dense breast tissue or when medically
19    necessary as determined by a physician licensed to
20    practice medicine in all of its branches.
21        (4.5) For a group policy of accident and health
22    insurance that is amended, delivered, issued, or renewed
23    on or after the effective date of this amendatory Act of
24    the 103rd General Assembly, molecular breast imaging (MBI)
25    and magnetic resonance imaging of an entire breast or
26    breasts if a mammogram demonstrates heterogeneous or dense

 

 

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1    breast tissue or when medically necessary as determined by
2    a physician licensed to practice medicine in all of its
3    branches, advanced practice registered nurse, or physician
4    assistant.
5        (5) For a group policy of accident and health
6    insurance that is amended, delivered, issued, or renewed
7    on or after January 1, 2020, (the effective date of Public
8    Act 101-580) this amendatory Act of the 101st General
9    Assembly, a diagnostic mammogram when medically necessary,
10    as determined by a physician licensed to practice medicine
11    in all its branches, advanced practice registered nurse,
12    or physician assistant.
13    A policy subject to this subsection shall not impose a
14deductible, coinsurance, copayment, or any other cost-sharing
15requirement on the coverage provided; except that this
16sentence does not apply to coverage of diagnostic mammograms
17to the extent such coverage would disqualify a high-deductible
18health plan from eligibility for a health savings account
19pursuant to Section 223 of the Internal Revenue Code (26
20U.S.C. 223).
21    For purposes of this subsection:
22    "Diagnostic mammogram" means a mammogram obtained using
23diagnostic mammography.
24    "Diagnostic mammography" means a method of screening that
25is designed to evaluate an abnormality in a breast, including
26an abnormality seen or suspected on a screening mammogram or a

 

 

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1subjective or objective abnormality otherwise detected in the
2breast.
3    "Low-dose mammography" means the x-ray examination of the
4breast using equipment dedicated specifically for mammography,
5including the x-ray tube, filter, compression device, and
6image receptor, with an average radiation exposure delivery of
7less than one rad per breast for 2 views of an average size
8breast. The term also includes digital mammography.
9    (d-5) Coverage as described by subsection (d) shall be
10provided at no cost to the insured and shall not be applied to
11an annual or lifetime maximum benefit.
12    (d-10) When health care services are available through
13contracted providers and a person does not comply with plan
14provisions specific to the use of contracted providers, the
15requirements of subsection (d-5) are not applicable. When a
16person does not comply with plan provisions specific to the
17use of contracted providers, plan provisions specific to the
18use of non-contracted providers must be applied without
19distinction for coverage required by this Section and shall be
20at least as favorable as for other radiological examinations
21covered by the policy or contract.
22    (d-15) If a municipality, including a home rule
23municipality, is a self-insurer for purposes of providing
24health insurance coverage for its employees, the insurance
25coverage shall include mastectomy coverage, which includes
26coverage for prosthetic devices or reconstructive surgery

 

 

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1incident to the mastectomy. Coverage for breast reconstruction
2in connection with a mastectomy shall include:
3        (1) reconstruction of the breast upon which the
4    mastectomy has been performed;
5        (2) surgery and reconstruction of the other breast to
6    produce a symmetrical appearance; and
7        (3) prostheses and treatment for physical
8    complications at all stages of mastectomy, including
9    lymphedemas.
10Care shall be determined in consultation with the attending
11physician and the patient. The offered coverage for prosthetic
12devices and reconstructive surgery shall be subject to the
13deductible and coinsurance conditions applied to the
14mastectomy, and all other terms and conditions applicable to
15other benefits. When a mastectomy is performed and there is no
16evidence of malignancy then the offered coverage may be
17limited to the provision of prosthetic devices and
18reconstructive surgery to within 2 years after the date of the
19mastectomy. As used in this Section, "mastectomy" means the
20removal of all or part of the breast for medically necessary
21reasons, as determined by a licensed physician.
22    A municipality, including a home rule municipality, that
23is a self-insurer for purposes of providing health insurance
24coverage for its employees, may not penalize or reduce or
25limit the reimbursement of an attending provider or provide
26incentives (monetary or otherwise) to an attending provider to

 

 

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1induce the provider to provide care to an insured in a manner
2inconsistent with this Section.
3    (d-20) The requirement that mammograms be included in
4health insurance coverage as provided in subsections (d)
5through (d-15) is an exclusive power and function of the State
6and is a denial and limitation under Article VII, Section 6,
7subsection (h) of the Illinois Constitution of home rule
8municipality powers. A home rule municipality to which
9subsections (d) through (d-15) apply must comply with every
10provision of those subsections.
11    (e) Rulemaking authority to implement Public Act 95-1045,
12if any, is conditioned on the rules being adopted in
13accordance with all provisions of the Illinois Administrative
14Procedure Act and all rules and procedures of the Joint
15Committee on Administrative Rules; any purported rule not so
16adopted, for whatever reason, is unauthorized.
17(Source: P.A. 100-863, eff. 8-14-18; 101-580, eff. 1-1-20.)
 
18    Section 15. The Illinois Insurance Code is amended by
19changing Section 356g as follows:
 
20    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
21    Sec. 356g. Mammograms; mastectomies.
22    (a) Every insurer shall provide in each group or
23individual policy, contract, or certificate of insurance
24issued or renewed for persons who are residents of this State,

 

 

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1coverage for screening by low-dose mammography for all
2patients women 35 years of age or older for the presence of
3occult breast cancer within the provisions of the policy,
4contract, or certificate. The coverage shall be as follows:
5         (1) A baseline mammogram for patients women 35 to 39
6    years of age.
7         (2) An annual mammogram for patients women 40 years
8    of age or older.
9         (3) A mammogram at the age and intervals considered
10    medically necessary by the patient's woman's health care
11    provider for patients women under 40 years of age and
12    having a family history of breast cancer, prior personal
13    history of breast cancer, positive genetic testing, or
14    other risk factors.
15        (4) For an individual or group policy of accident and
16    health insurance or a managed care plan that is amended,
17    delivered, issued, or renewed on or after January 1, 2020
18    (the effective date of Public Act 101-580) and before the
19    effective date of this amendatory Act of the 103rd General
20    Assembly this amendatory Act of the 101st General
21    Assembly, a comprehensive ultrasound screening and MRI of
22    an entire breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue or when medically
24    necessary as determined by a physician licensed to
25    practice medicine in all of its branches.
26        (4.3) For an individual or group policy of accident

 

 

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1    and health insurance or a managed care plan that is
2    amended, delivered, issued, or renewed on or after the
3    effective date of this amendatory Act of the 103rd General
4    Assembly, a comprehensive ultrasound screening and MRI of
5    an entire breast or breasts if a mammogram demonstrates
6    heterogeneous or dense breast tissue or when medically
7    necessary as determined by a physician licensed to
8    practice medicine in all of its branches, advanced
9    practice registered nurse, or physician assistant.
10        (4.5) For a group policy of accident and health
11    insurance that is amended, delivered, issued, or renewed
12    on or after the effective date of this amendatory Act of
13    the 103rd General Assembly, molecular breast imaging (MBI)
14    of an entire breast or breasts if a mammogram demonstrates
15    heterogeneous or dense breast tissue or when medically
16    necessary as determined by a physician licensed to
17    practice medicine in all of its branches, advanced
18    practice registered nurse, or physician assistant.
19        (5) A screening MRI when medically necessary, as
20    determined by a physician licensed to practice medicine in
21    all of its branches.
22        (6) For an individual or group policy of accident and
23    health insurance or a managed care plan that is amended,
24    delivered, issued, or renewed on or after January 1, 2020
25    (the effective date of Public Act 101-580) this amendatory
26    Act of the 101st General Assembly, a diagnostic mammogram

 

 

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1    when medically necessary, as determined by a physician
2    licensed to practice medicine in all its branches,
3    advanced practice registered nurse, or physician
4    assistant.
5    A policy subject to this subsection shall not impose a
6deductible, coinsurance, copayment, or any other cost-sharing
7requirement on the coverage provided; except that this
8sentence does not apply to coverage of diagnostic mammograms
9to the extent such coverage would disqualify a high-deductible
10health plan from eligibility for a health savings account
11pursuant to Section 223 of the Internal Revenue Code (26
12U.S.C. 223).
13    For purposes of this Section:
14    "Diagnostic mammogram" means a mammogram obtained using
15diagnostic mammography.
16    "Diagnostic mammography" means a method of screening that
17is designed to evaluate an abnormality in a breast, including
18an abnormality seen or suspected on a screening mammogram or a
19subjective or objective abnormality otherwise detected in the
20breast.
21    "Low-dose mammography" means the x-ray examination of the
22breast using equipment dedicated specifically for mammography,
23including the x-ray tube, filter, compression device, and
24image receptor, with radiation exposure delivery of less than
251 rad per breast for 2 views of an average size breast. The
26term also includes digital mammography and includes breast

 

 

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1tomosynthesis. As used in this Section, the term "breast
2tomosynthesis" means a radiologic procedure that involves the
3acquisition of projection images over the stationary breast to
4produce cross-sectional digital three-dimensional images of
5the breast.
6    If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage for breast tomosynthesis outlined in this
16subsection, then the requirement that an insurer cover breast
17tomosynthesis is inoperative other than any such coverage
18authorized under Section 1902 of the Social Security Act, 42
19U.S.C. 1396a, and the State shall not assume any obligation
20for the cost of coverage for breast tomosynthesis set forth in
21this subsection.
22    (a-5) Coverage as described by subsection (a) shall be
23provided at no cost to the insured and shall not be applied to
24an annual or lifetime maximum benefit.
25    (a-10) When health care services are available through
26contracted providers and a person does not comply with plan

 

 

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1provisions specific to the use of contracted providers, the
2requirements of subsection (a-5) are not applicable. When a
3person does not comply with plan provisions specific to the
4use of contracted providers, plan provisions specific to the
5use of non-contracted providers must be applied without
6distinction for coverage required by this Section and shall be
7at least as favorable as for other radiological examinations
8covered by the policy or contract.
9    (b) No policy of accident or health insurance that
10provides for the surgical procedure known as a mastectomy
11shall be issued, amended, delivered, or renewed in this State
12unless that coverage also provides for prosthetic devices or
13reconstructive surgery incident to the mastectomy. Coverage
14for breast reconstruction in connection with a mastectomy
15shall include:
16        (1) reconstruction of the breast upon which the
17    mastectomy has been performed;
18        (2) surgery and reconstruction of the other breast to
19    produce a symmetrical appearance; and
20        (3) prostheses and treatment for physical
21    complications at all stages of mastectomy, including
22    lymphedemas.
23Care shall be determined in consultation with the attending
24physician and the patient. The offered coverage for prosthetic
25devices and reconstructive surgery shall be subject to the
26deductible and coinsurance conditions applied to the

 

 

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1mastectomy, and all other terms and conditions applicable to
2other benefits. When a mastectomy is performed and there is no
3evidence of malignancy then the offered coverage may be
4limited to the provision of prosthetic devices and
5reconstructive surgery to within 2 years after the date of the
6mastectomy. As used in this Section, "mastectomy" means the
7removal of all or part of the breast for medically necessary
8reasons, as determined by a licensed physician.
9    Written notice of the availability of coverage under this
10Section shall be delivered to the insured upon enrollment and
11annually thereafter. An insurer may not deny to an insured
12eligibility, or continued eligibility, to enroll or to renew
13coverage under the terms of the plan solely for the purpose of
14avoiding the requirements of this Section. An insurer may not
15penalize or reduce or limit the reimbursement of an attending
16provider or provide incentives (monetary or otherwise) to an
17attending provider to induce the provider to provide care to
18an insured in a manner inconsistent with this Section.
19    (c) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in
21accordance with all provisions of the Illinois Administrative
22Procedure Act and all rules and procedures of the Joint
23Committee on Administrative Rules; any purported rule not so
24adopted, for whatever reason, is unauthorized.
25(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
 

 

 

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1    Section 20. The Health Maintenance Organization Act is
2amended by changing Sections 4-6.1 and 5-3 as follows:
 
3    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
4    Sec. 4-6.1. Mammograms; mastectomies.
5    (a) Every contract or evidence of coverage issued by a
6Health Maintenance Organization for persons who are residents
7of this State shall contain coverage for screening by low-dose
8mammography for all patients women 35 years of age or older for
9the presence of occult breast cancer. The coverage shall be as
10follows:
11        (1) A baseline mammogram for patients women 35 to 39
12    years of age.
13        (2) An annual mammogram for patients women 40 years of
14    age or older.
15        (3) A mammogram at the age and intervals considered
16    medically necessary by the patient's woman's health care
17    provider for patients women under 40 years of age and
18    having a family history of breast cancer, prior personal
19    history of breast cancer, positive genetic testing, or
20    other risk factors.
21        (4) For an individual or group policy of accident and
22    health insurance or a managed care plan that is amended,
23    delivered, issued, or renewed on or after January 1, 2020
24    (the effective date of Public Act 101-580) and before the
25    effective date of this amendatory Act of the 103rd General

 

 

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1    Assembly this amendatory Act of the 101st General
2    Assembly, a comprehensive ultrasound screening and MRI of
3    an entire breast or breasts if a mammogram demonstrates
4    heterogeneous or dense breast tissue or when medically
5    necessary as determined by a physician licensed to
6    practice medicine in all of its branches.
7        (4.3) For an individual or group policy of accident
8    and health insurance or a managed care plan that is
9    amended, delivered, issued, or renewed on or after the
10    effective date of this amendatory Act of the 103rd General
11    Assembly, a comprehensive ultrasound screening and MRI of
12    an entire breast or breasts if a mammogram demonstrates
13    heterogeneous or dense breast tissue or when medically
14    necessary as determined by a physician licensed to
15    practice medicine in all of its branches, advanced
16    practice registered nurse, or physician assistant.
17        (4.5) For a group policy of accident and health
18    insurance that is amended, delivered, issued, or renewed
19    on or after the effective date of this amendatory Act of
20    the 103rd General Assembly, molecular breast imaging (MBI)
21    of an entire breast or breasts if a mammogram demonstrates
22    heterogeneous or dense breast tissue or when medically
23    necessary as determined by a physician licensed to
24    practice medicine in all of its branches, advanced
25    practice registered nurse, or physician assistant.
26        (5) For an individual or group policy of accident and

 

 

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1    health insurance or a managed care plan that is amended,
2    delivered, issued, or renewed on or after January 1, 2020
3    (the effective date of Public Act 101-580) this amendatory
4    Act of the 101st General Assembly, a diagnostic mammogram
5    when medically necessary, as determined by a physician
6    licensed to practice medicine in all its branches,
7    advanced practice registered nurse, or physician
8    assistant.
9    A policy subject to this subsection shall not impose a
10deductible, coinsurance, copayment, or any other cost-sharing
11requirement on the coverage provided; except that this
12sentence does not apply to coverage of diagnostic mammograms
13to the extent such coverage would disqualify a high-deductible
14health plan from eligibility for a health savings account
15pursuant to Section 223 of the Internal Revenue Code (26
16U.S.C. 223).
17    For purposes of this Section:
18    "Diagnostic mammogram" means a mammogram obtained using
19diagnostic mammography.
20    "Diagnostic mammography" means a method of screening that
21is designed to evaluate an abnormality in a breast, including
22an abnormality seen or suspected on a screening mammogram or a
23subjective or objective abnormality otherwise detected in the
24breast.
25    "Low-dose mammography" means the x-ray examination of the
26breast using equipment dedicated specifically for mammography,

 

 

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1including the x-ray tube, filter, compression device, and
2image receptor, with radiation exposure delivery of less than
31 rad per breast for 2 views of an average size breast. The
4term also includes digital mammography and includes breast
5tomosynthesis.
6    "Breast tomosynthesis" means a radiologic procedure that
7involves the acquisition of projection images over the
8stationary breast to produce cross-sectional digital
9three-dimensional images of the breast.
10    If, at any time, the Secretary of the United States
11Department of Health and Human Services, or its successor
12agency, promulgates rules or regulations to be published in
13the Federal Register or publishes a comment in the Federal
14Register or issues an opinion, guidance, or other action that
15would require the State, pursuant to any provision of the
16Patient Protection and Affordable Care Act (Public Law
17111-148), including, but not limited to, 42 U.S.C.
1818031(d)(3)(B) or any successor provision, to defray the cost
19of any coverage for breast tomosynthesis outlined in this
20subsection, then the requirement that an insurer cover breast
21tomosynthesis is inoperative other than any such coverage
22authorized under Section 1902 of the Social Security Act, 42
23U.S.C. 1396a, and the State shall not assume any obligation
24for the cost of coverage for breast tomosynthesis set forth in
25this subsection.
26    (a-5) Coverage as described in subsection (a) shall be

 

 

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1provided at no cost to the enrollee and shall not be applied to
2an annual or lifetime maximum benefit.
3    (b) No contract or evidence of coverage issued by a health
4maintenance organization that provides for the surgical
5procedure known as a mastectomy shall be issued, amended,
6delivered, or renewed in this State on or after July 3, 2001
7(the effective date of Public Act 92-0048) this amendatory Act
8of the 92nd General Assembly unless that coverage also
9provides for prosthetic devices or reconstructive surgery
10incident to the mastectomy, providing that the mastectomy is
11performed after July 3, 2001 the effective date of this
12amendatory Act. Coverage for breast reconstruction in
13connection with a mastectomy shall include:
14        (1) reconstruction of the breast upon which the
15    mastectomy has been performed;
16        (2) surgery and reconstruction of the other breast to
17    produce a symmetrical appearance; and
18        (3) prostheses and treatment for physical
19    complications at all stages of mastectomy, including
20    lymphedemas.
21Care shall be determined in consultation with the attending
22physician and the patient. The offered coverage for prosthetic
23devices and reconstructive surgery shall be subject to the
24deductible and coinsurance conditions applied to the
25mastectomy and all other terms and conditions applicable to
26other benefits. When a mastectomy is performed and there is no

 

 

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1evidence of malignancy, then the offered coverage may be
2limited to the provision of prosthetic devices and
3reconstructive surgery to within 2 years after the date of the
4mastectomy. As used in this Section, "mastectomy" means the
5removal of all or part of the breast for medically necessary
6reasons, as determined by a licensed physician.
7    Written notice of the availability of coverage under this
8Section shall be delivered to the enrollee upon enrollment and
9annually thereafter. A health maintenance organization may not
10deny to an enrollee eligibility, or continued eligibility, to
11enroll or to renew coverage under the terms of the plan solely
12for the purpose of avoiding the requirements of this Section.
13A health maintenance organization may not penalize or reduce
14or limit the reimbursement of an attending provider or provide
15incentives (monetary or otherwise) to an attending provider to
16induce the provider to provide care to an insured in a manner
17inconsistent with this Section.
18    (c) Rulemaking authority to implement this amendatory Act
19of the 95th General Assembly, if any, is conditioned on the
20rules being adopted in accordance with all provisions of the
21Illinois Administrative Procedure Act and all rules and
22procedures of the Joint Committee on Administrative Rules; any
23purported rule not so adopted, for whatever reason, is
24unauthorized.
25(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
 

 

 

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1    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2    Sec. 5-3. Insurance Code provisions.
3    (a) Health Maintenance Organizations shall be subject to
4the provisions of Sections 133, 134, 136, 137, 139, 140,
5141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
6154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
7355.2, 355.3, 355b, 355c, 356f, 356g, 356g.5-1, 356m, 356q,
8356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
9356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
11356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
12356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
13356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
14356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
15356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
16356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
17356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
18368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
19408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
20subsection (2) of Section 367, and Articles IIA, VIII 1/2,
21XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
22Illinois Insurance Code.
23    (b) For purposes of the Illinois Insurance Code, except
24for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
25Health Maintenance Organizations in the following categories
26are deemed to be "domestic companies":

 

 

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1        (1) a corporation authorized under the Dental Service
2    Plan Act or the Voluntary Health Services Plans Act;
3        (2) a corporation organized under the laws of this
4    State; or
5        (3) a corporation organized under the laws of another
6    state, 30% or more of the enrollees of which are residents
7    of this State, except a corporation subject to
8    substantially the same requirements in its state of
9    organization as is a "domestic company" under Article VIII
10    1/2 of the Illinois Insurance Code.
11    (c) In considering the merger, consolidation, or other
12acquisition of control of a Health Maintenance Organization
13pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14        (1) the Director shall give primary consideration to
15    the continuation of benefits to enrollees and the
16    financial conditions of the acquired Health Maintenance
17    Organization after the merger, consolidation, or other
18    acquisition of control takes effect;
19        (2)(i) the criteria specified in subsection (1)(b) of
20    Section 131.8 of the Illinois Insurance Code shall not
21    apply and (ii) the Director, in making his determination
22    with respect to the merger, consolidation, or other
23    acquisition of control, need not take into account the
24    effect on competition of the merger, consolidation, or
25    other acquisition of control;
26        (3) the Director shall have the power to require the

 

 

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1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including, without limitation, the health
22maintenance organization's right, title, and interest in and
23to its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria

 

 

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1specified in Section 141.2 of the Illinois Insurance Code,
2take into account the effect of the management contract or
3service agreement on the continuation of benefits to enrollees
4and the financial condition of the health maintenance
5organization to be managed or serviced, and (ii) need not take
6into account the effect of the management contract or service
7agreement on competition.
8    (f) Except for small employer groups as defined in the
9Small Employer Rating, Renewability and Portability Health
10Insurance Act and except for medicare supplement policies as
11defined in Section 363 of the Illinois Insurance Code, a
12Health Maintenance Organization may by contract agree with a
13group or other enrollment unit to effect refunds or charge
14additional premiums under the following terms and conditions:
15        (i) the amount of, and other terms and conditions with
16    respect to, the refund or additional premium are set forth
17    in the group or enrollment unit contract agreed in advance
18    of the period for which a refund is to be paid or
19    additional premium is to be charged (which period shall
20    not be less than one year); and
21        (ii) the amount of the refund or additional premium
22    shall not exceed 20% of the Health Maintenance
23    Organization's profitable or unprofitable experience with
24    respect to the group or other enrollment unit for the
25    period (and, for purposes of a refund or additional
26    premium, the profitable or unprofitable experience shall

 

 

HB4180 Enrolled- 31 -LRB103 34255 MXP 64081 b

1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and
20the resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,

 

 

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1if any, is conditioned on the rules being adopted in
2accordance with all provisions of the Illinois Administrative
3Procedure Act and all rules and procedures of the Joint
4Committee on Administrative Rules; any purported rule not so
5adopted, for whatever reason, is unauthorized.
6(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
7102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
81-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
9eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
10102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
111-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
12eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
13103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
146-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
15eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
16    Section 25. The Illinois Public Aid Code is amended by
17changing Section 5-5 as follows:
 
18    (305 ILCS 5/5-5)
19    Sec. 5-5. Medical services. The Illinois Department, by
20rule, shall determine the quantity and quality of and the rate
21of reimbursement for the medical assistance for which payment
22will be authorized, and the medical services to be provided,
23which may include all or part of the following: (1) inpatient
24hospital services; (2) outpatient hospital services; (3) other

 

 

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1laboratory and X-ray services; (4) skilled nursing home
2services; (5) physicians' services whether furnished in the
3office, the patient's home, a hospital, a skilled nursing
4home, or elsewhere; (6) medical care, or any other type of
5remedial care furnished by licensed practitioners; (7) home
6health care services; (8) private duty nursing service; (9)
7clinic services; (10) dental services, including prevention
8and treatment of periodontal disease and dental caries disease
9for pregnant individuals, provided by an individual licensed
10to practice dentistry or dental surgery; for purposes of this
11item (10), "dental services" means diagnostic, preventive, or
12corrective procedures provided by or under the supervision of
13a dentist in the practice of his or her profession; (11)
14physical therapy and related services; (12) prescribed drugs,
15dentures, and prosthetic devices; and eyeglasses prescribed by
16a physician skilled in the diseases of the eye, or by an
17optometrist, whichever the person may select; (13) other
18diagnostic, screening, preventive, and rehabilitative
19services, including to ensure that the individual's need for
20intervention or treatment of mental disorders or substance use
21disorders or co-occurring mental health and substance use
22disorders is determined using a uniform screening, assessment,
23and evaluation process inclusive of criteria, for children and
24adults; for purposes of this item (13), a uniform screening,
25assessment, and evaluation process refers to a process that
26includes an appropriate evaluation and, as warranted, a

 

 

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

 

 

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1reproductive health care that is otherwise legal in Illinois
2shall be covered under the medical assistance program for
3persons who are otherwise eligible for medical assistance
4under this Article.
5    Notwithstanding any other provision of this Section, all
6tobacco cessation medications approved by the United States
7Food and Drug Administration and all individual and group
8tobacco cessation counseling services and telephone-based
9counseling services and tobacco cessation medications provided
10through the Illinois Tobacco Quitline shall be covered under
11the medical assistance program for persons who are otherwise
12eligible for assistance under this Article. The Department
13shall comply with all federal requirements necessary to obtain
14federal financial participation, as specified in 42 CFR
15433.15(b)(7), for telephone-based counseling services provided
16through the Illinois Tobacco Quitline, including, but not
17limited to: (i) entering into a memorandum of understanding or
18interagency agreement with the Department of Public Health, as
19administrator of the Illinois Tobacco Quitline; and (ii)
20developing a cost allocation plan for Medicaid-allowable
21Illinois Tobacco Quitline services in accordance with 45 CFR
2295.507. The Department shall submit the memorandum of
23understanding or interagency agreement, the cost allocation
24plan, and all other necessary documentation to the Centers for
25Medicare and Medicaid Services for review and approval.
26Coverage under this paragraph shall be contingent upon federal

 

 

HB4180 Enrolled- 36 -LRB103 34255 MXP 64081 b

1approval.
2    Notwithstanding any other provision of this Code, the
3Illinois Department may not require, as a condition of payment
4for any laboratory test authorized under this Article, that a
5physician's handwritten signature appear on the laboratory
6test order form. The Illinois Department may, however, impose
7other appropriate requirements regarding laboratory test order
8documentation.
9    Upon receipt of federal approval of an amendment to the
10Illinois Title XIX State Plan for this purpose, the Department
11shall authorize the Chicago Public Schools (CPS) to procure a
12vendor or vendors to manufacture eyeglasses for individuals
13enrolled in a school within the CPS system. CPS shall ensure
14that its vendor or vendors are enrolled as providers in the
15medical assistance program and in any capitated Medicaid
16managed care entity (MCE) serving individuals enrolled in a
17school within the CPS system. Under any contract procured
18under this provision, the vendor or vendors must serve only
19individuals enrolled in a school within the CPS system. Claims
20for services provided by CPS's vendor or vendors to recipients
21of benefits in the medical assistance program under this Code,
22the Children's Health Insurance Program, or the Covering ALL
23KIDS Health Insurance Program shall be submitted to the
24Department or the MCE in which the individual is enrolled for
25payment and shall be reimbursed at the Department's or the
26MCE's established rates or rate methodologies for eyeglasses.

 

 

HB4180 Enrolled- 37 -LRB103 34255 MXP 64081 b

1    On and after July 1, 2012, the Department of Healthcare
2and Family Services may provide the following services to
3persons eligible for assistance under this Article who are
4participating in education, training or employment programs
5operated by the Department of Human Services as successor to
6the Department of Public Aid:
7        (1) dental services provided by or under the
8    supervision of a dentist; and
9        (2) eyeglasses prescribed by a physician skilled in
10    the diseases of the eye, or by an optometrist, whichever
11    the person may select.
12    On and after July 1, 2018, the Department of Healthcare
13and Family Services shall provide dental services to any adult
14who is otherwise eligible for assistance under the medical
15assistance program. As used in this paragraph, "dental
16services" means diagnostic, preventative, restorative, or
17corrective procedures, including procedures and services for
18the prevention and treatment of periodontal disease and dental
19caries disease, provided by an individual who is licensed to
20practice dentistry or dental surgery or who is under the
21supervision of a dentist in the practice of his or her
22profession.
23    On and after July 1, 2018, targeted dental services, as
24set forth in Exhibit D of the Consent Decree entered by the
25United States District Court for the Northern District of
26Illinois, Eastern Division, in the matter of Memisovski v.

 

 

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1Maram, Case No. 92 C 1982, that are provided to adults under
2the medical assistance program shall be established at no less
3than the rates set forth in the "New Rate" column in Exhibit D
4of the Consent Decree for targeted dental services that are
5provided to persons under the age of 18 under the medical
6assistance program.
7    Notwithstanding any other provision of this Code and
8subject to federal approval, the Department may adopt rules to
9allow a dentist who is volunteering his or her service at no
10cost to render dental services through an enrolled
11not-for-profit health clinic without the dentist personally
12enrolling as a participating provider in the medical
13assistance program. A not-for-profit health clinic shall
14include a public health clinic or Federally Qualified Health
15Center or other enrolled provider, as determined by the
16Department, through which dental services covered under this
17Section are performed. The Department shall establish a
18process for payment of claims for reimbursement for covered
19dental services rendered under this provision.
20    On and after January 1, 2022, the Department of Healthcare
21and Family Services shall administer and regulate a
22school-based dental program that allows for the out-of-office
23delivery of preventative dental services in a school setting
24to children under 19 years of age. The Department shall
25establish, by rule, guidelines for participation by providers
26and set requirements for follow-up referral care based on the

 

 

HB4180 Enrolled- 39 -LRB103 34255 MXP 64081 b

1requirements established in the Dental Office Reference Manual
2published by the Department that establishes the requirements
3for dentists participating in the All Kids Dental School
4Program. Every effort shall be made by the Department when
5developing the program requirements to consider the different
6geographic differences of both urban and rural areas of the
7State for initial treatment and necessary follow-up care. No
8provider shall be charged a fee by any unit of local government
9to participate in the school-based dental program administered
10by the Department. Nothing in this paragraph shall be
11construed to limit or preempt a home rule unit's or school
12district's authority to establish, change, or administer a
13school-based dental program in addition to, or independent of,
14the school-based dental program administered by the
15Department.
16    The Illinois Department, by rule, may distinguish and
17classify the medical services to be provided only in
18accordance with the classes of persons designated in Section
195-2.
20    The Department of Healthcare and Family Services must
21provide coverage and reimbursement for amino acid-based
22elemental formulas, regardless of delivery method, for the
23diagnosis and treatment of (i) eosinophilic disorders and (ii)
24short bowel syndrome when the prescribing physician has issued
25a written order stating that the amino acid-based elemental
26formula is medically necessary.

 

 

HB4180 Enrolled- 40 -LRB103 34255 MXP 64081 b

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

 

 

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

 

 

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1breast.
2    "Low-dose mammography" means the x-ray examination of the
3breast using equipment dedicated specifically for mammography,
4including the x-ray tube, filter, compression device, and
5image receptor, with an average radiation exposure delivery of
6less than one rad per breast for 2 views of an average size
7breast. The term also includes digital mammography and
8includes breast tomosynthesis.
9    "Breast tomosynthesis" means a radiologic procedure that
10involves the acquisition of projection images over the
11stationary breast to produce cross-sectional digital
12three-dimensional images of the breast.
13    If, at any time, the Secretary of the United States
14Department of Health and Human Services, or its successor
15agency, promulgates rules or regulations to be published in
16the Federal Register or publishes a comment in the Federal
17Register or issues an opinion, guidance, or other action that
18would require the State, pursuant to any provision of the
19Patient Protection and Affordable Care Act (Public Law
20111-148), including, but not limited to, 42 U.S.C.
2118031(d)(3)(B) or any successor provision, to defray the cost
22of any coverage for breast tomosynthesis outlined in this
23paragraph, then the requirement that an insurer cover breast
24tomosynthesis is inoperative other than any such coverage
25authorized under Section 1902 of the Social Security Act, 42
26U.S.C. 1396a, and the State shall not assume any obligation

 

 

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1for the cost of coverage for breast tomosynthesis set forth in
2this paragraph.
3    On and after January 1, 2016, the Department shall ensure
4that all networks of care for adult clients of the Department
5include access to at least one breast imaging Center of
6Imaging Excellence as certified by the American College of
7Radiology.
8    On and after January 1, 2012, providers participating in a
9quality improvement program approved by the Department shall
10be reimbursed for screening and diagnostic mammography at the
11same rate as the Medicare program's rates, including the
12increased reimbursement for digital mammography and, after
13January 1, 2023 (the effective date of Public Act 102-1018),
14breast tomosynthesis.
15    The Department shall convene an expert panel including
16representatives of hospitals, free-standing mammography
17facilities, and doctors, including radiologists, to establish
18quality standards for mammography.
19    On and after January 1, 2017, providers participating in a
20breast cancer treatment quality improvement program approved
21by the Department shall be reimbursed for breast cancer
22treatment at a rate that is no lower than 95% of the Medicare
23program's rates for the data elements included in the breast
24cancer treatment quality program.
25    The Department shall convene an expert panel, including
26representatives of hospitals, free-standing breast cancer

 

 

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1treatment centers, breast cancer quality organizations, and
2doctors, including radiologists that are trained in all forms
3of FDA approved breast imaging technologies, breast surgeons,
4reconstructive breast surgeons, oncologists, and primary care
5providers to establish quality standards for breast cancer
6treatment.
7    Subject to federal approval, the Department shall
8establish a rate methodology for mammography at federally
9qualified health centers and other encounter-rate clinics.
10These clinics or centers may also collaborate with other
11hospital-based mammography facilities. By January 1, 2016, the
12Department shall report to the General Assembly on the status
13of the provision set forth in this paragraph.
14    The Department shall establish a methodology to remind
15individuals who are age-appropriate for screening mammography,
16but who have not received a mammogram within the previous 18
17months, of the importance and benefit of screening
18mammography. The Department shall work with experts in breast
19cancer outreach and patient navigation to optimize these
20reminders and shall establish a methodology for evaluating
21their effectiveness and modifying the methodology based on the
22evaluation.
23    The Department shall establish a performance goal for
24primary care providers with respect to their female patients
25over age 40 receiving an annual mammogram. This performance
26goal shall be used to provide additional reimbursement in the

 

 

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

 

 

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1marketing by the federal Food and Drug Administration for all
2persons between the ages of 9 and 45. Subject to federal
3approval, the Department shall provide coverage and
4reimbursement for a human papillomavirus (HPV) vaccine for
5persons of the age of 46 and above who have been diagnosed with
6cervical dysplasia with a high risk of recurrence or
7progression. The Department shall disallow any
8preauthorization requirements for the administration of the
9human papillomavirus (HPV) vaccine.
10    On or after July 1, 2022, individuals who are otherwise
11eligible for medical assistance under this Article shall
12receive coverage for perinatal depression screenings for the
1312-month period beginning on the last day of their pregnancy.
14Medical assistance coverage under this paragraph shall be
15conditioned on the use of a screening instrument approved by
16the Department.
17    Any medical or health care provider shall immediately
18recommend, to any pregnant individual who is being provided
19prenatal services and is suspected of having a substance use
20disorder as defined in the Substance Use Disorder Act,
21referral to a local substance use disorder treatment program
22licensed by the Department of Human Services or to a licensed
23hospital which provides substance abuse treatment services.
24The Department of Healthcare and Family Services shall assure
25coverage for the cost of treatment of the drug abuse or
26addiction for pregnant recipients in accordance with the

 

 

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

 

 

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1providing regular advice on policy and administrative matters,
2information dissemination and educational activities for
3medical and health care providers, and consistency in
4procedures to the Illinois Department.
5    The Illinois Department may develop and contract with
6Partnerships of medical providers to arrange medical services
7for persons eligible under Section 5-2 of this Code.
8Implementation of this Section may be by demonstration
9projects in certain geographic areas. The Partnership shall be
10represented by a sponsor organization. The Department, by
11rule, shall develop qualifications for sponsors of
12Partnerships. Nothing in this Section shall be construed to
13require that the sponsor organization be a medical
14organization.
15    The sponsor must negotiate formal written contracts with
16medical providers for physician services, inpatient and
17outpatient hospital care, home health services, treatment for
18alcoholism and substance abuse, and other services determined
19necessary by the Illinois Department by rule for delivery by
20Partnerships. Physician services must include prenatal and
21obstetrical care. The Illinois Department shall reimburse
22medical services delivered by Partnership providers to clients
23in target areas according to provisions of this Article and
24the Illinois Health Finance Reform Act, except that:
25        (1) Physicians participating in a Partnership and
26    providing certain services, which shall be determined by

 

 

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1    the Illinois Department, to persons in areas covered by
2    the Partnership may receive an additional surcharge for
3    such services.
4        (2) The Department may elect to consider and negotiate
5    financial incentives to encourage the development of
6    Partnerships and the efficient delivery of medical care.
7        (3) Persons receiving medical services through
8    Partnerships may receive medical and case management
9    services above the level usually offered through the
10    medical assistance program.
11    Medical providers shall be required to meet certain
12qualifications to participate in Partnerships to ensure the
13delivery of high quality medical services. These
14qualifications shall be determined by rule of the Illinois
15Department and may be higher than qualifications for
16participation in the medical assistance program. Partnership
17sponsors may prescribe reasonable additional qualifications
18for participation by medical providers, only with the prior
19written approval of the Illinois Department.
20    Nothing in this Section shall limit the free choice of
21practitioners, hospitals, and other providers of medical
22services by clients. In order to ensure patient freedom of
23choice, the Illinois Department shall immediately promulgate
24all rules and take all other necessary actions so that
25provided services may be accessed from therapeutically
26certified optometrists to the full extent of the Illinois

 

 

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

 

 

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1prescription drugs, dentures, prosthetic devices and
2eyeglasses by eligible persons under this Section accompany
3each claim for reimbursement submitted by the dispenser of
4such medical services. No such claims for reimbursement shall
5be approved for payment by the Illinois Department without
6such proof of receipt, unless the Illinois Department shall
7have put into effect and shall be operating a system of
8post-payment audit and review which shall, on a sampling
9basis, be deemed adequate by the Illinois Department to assure
10that such drugs, dentures, prosthetic devices and eyeglasses
11for which payment is being made are actually being received by
12eligible recipients. Within 90 days after September 16, 1984
13(the effective date of Public Act 83-1439), the Illinois
14Department shall establish a current list of acquisition costs
15for all prosthetic devices and any other items recognized as
16medical equipment and supplies reimbursable under this Article
17and shall update such list on a quarterly basis, except that
18the acquisition costs of all prescription drugs shall be
19updated no less frequently than every 30 days as required by
20Section 5-5.12.
21    Notwithstanding any other law to the contrary, the
22Illinois Department shall, within 365 days after July 22, 2013
23(the effective date of Public Act 98-104), establish
24procedures to permit skilled care facilities licensed under
25the Nursing Home Care Act to submit monthly billing claims for
26reimbursement purposes. Following development of these

 

 

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1procedures, the Department shall, by July 1, 2016, test the
2viability of the new system and implement any necessary
3operational or structural changes to its information
4technology platforms in order to allow for the direct
5acceptance and payment of nursing home claims.
6    Notwithstanding any other law to the contrary, the
7Illinois Department shall, within 365 days after August 15,
82014 (the effective date of Public Act 98-963), establish
9procedures to permit ID/DD facilities licensed under the ID/DD
10Community Care Act and MC/DD facilities licensed under the
11MC/DD Act to submit monthly billing claims for reimbursement
12purposes. Following development of these procedures, the
13Department shall have an additional 365 days to test the
14viability of the new system and to ensure that any necessary
15operational or structural changes to its information
16technology platforms are implemented.
17    The Illinois Department shall require all dispensers of
18medical services, other than an individual practitioner or
19group of practitioners, desiring to participate in the Medical
20Assistance program established under this Article to disclose
21all financial, beneficial, ownership, equity, surety or other
22interests in any and all firms, corporations, partnerships,
23associations, business enterprises, joint ventures, agencies,
24institutions or other legal entities providing any form of
25health care services in this State under this Article.
26    The Illinois Department may require that all dispensers of

 

 

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1medical services desiring to participate in the medical
2assistance program established under this Article disclose,
3under such terms and conditions as the Illinois Department may
4by rule establish, all inquiries from clients and attorneys
5regarding medical bills paid by the Illinois Department, which
6inquiries could indicate potential existence of claims or
7liens for the Illinois Department.
8    Enrollment of a vendor shall be subject to a provisional
9period and shall be conditional for one year. During the
10period of conditional enrollment, the Department may terminate
11the vendor's eligibility to participate in, or may disenroll
12the vendor from, the medical assistance program without cause.
13Unless otherwise specified, such termination of eligibility or
14disenrollment is not subject to the Department's hearing
15process. However, a disenrolled vendor may reapply without
16penalty.
17    The Department has the discretion to limit the conditional
18enrollment period for vendors based upon the category of risk
19of the vendor.
20    Prior to enrollment and during the conditional enrollment
21period in the medical assistance program, all vendors shall be
22subject to enhanced oversight, screening, and review based on
23the risk of fraud, waste, and abuse that is posed by the
24category of risk of the vendor. The Illinois Department shall
25establish the procedures for oversight, screening, and review,
26which may include, but need not be limited to: criminal and

 

 

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

 

 

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1    complete.
2        (2) In the case of errors attributable to the Illinois
3    Department or any of its claims processing intermediaries
4    which result in an inability to receive, process, or
5    adjudicate a claim, the 180-day period shall not begin
6    until the provider has been notified of the error.
7        (3) In the case of a provider for whom the Illinois
8    Department initiates the monthly billing process.
9        (4) In the case of a provider operated by a unit of
10    local government with a population exceeding 3,000,000
11    when local government funds finance federal participation
12    for claims payments.
13    For claims for services rendered during a period for which
14a recipient received retroactive eligibility, claims must be
15filed within 180 days after the Department determines the
16applicant is eligible. For claims for which the Illinois
17Department is not the primary payer, claims must be submitted
18to the Illinois Department within 180 days after the final
19adjudication by the primary payer.
20    In the case of long term care facilities, within 120
21calendar days of receipt by the facility of required
22prescreening information, new admissions with associated
23admission documents shall be submitted through the Medical
24Electronic Data Interchange (MEDI) or the Recipient
25Eligibility Verification (REV) System or shall be submitted
26directly to the Department of Human Services using required

 

 

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

 

 

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1    The Illinois Department shall enter into agreements with
2State agencies and departments, and is authorized to enter
3into agreements with federal agencies and departments, under
4which such agencies and departments shall share data necessary
5for medical assistance program integrity functions and
6oversight. The Illinois Department shall develop, in
7cooperation with other State departments and agencies, and in
8compliance with applicable federal laws and regulations,
9appropriate and effective methods to share such data. At a
10minimum, and to the extent necessary to provide data sharing,
11the Illinois Department shall enter into agreements with State
12agencies and departments, and is authorized to enter into
13agreements with federal agencies and departments, including,
14but not limited to: the Secretary of State; the Department of
15Revenue; the Department of Public Health; the Department of
16Human Services; and the Department of Financial and
17Professional Regulation.
18    Beginning in fiscal year 2013, the Illinois Department
19shall set forth a request for information to identify the
20benefits of a pre-payment, post-adjudication, and post-edit
21claims system with the goals of streamlining claims processing
22and provider reimbursement, reducing the number of pending or
23rejected claims, and helping to ensure a more transparent
24adjudication process through the utilization of: (i) provider
25data verification and provider screening technology; and (ii)
26clinical code editing; and (iii) pre-pay, pre-adjudicated, or

 

 

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1post-adjudicated predictive modeling with an integrated case
2management system with link analysis. Such a request for
3information shall not be considered as a request for proposal
4or as an obligation on the part of the Illinois Department to
5take any action or acquire any products or services.
6    The Illinois Department shall establish policies,
7procedures, standards and criteria by rule for the
8acquisition, repair and replacement of orthotic and prosthetic
9devices and durable medical equipment. Such rules shall
10provide, but not be limited to, the following services: (1)
11immediate repair or replacement of such devices by recipients;
12and (2) rental, lease, purchase or lease-purchase of durable
13medical equipment in a cost-effective manner, taking into
14consideration the recipient's medical prognosis, the extent of
15the recipient's needs, and the requirements and costs for
16maintaining such equipment. Subject to prior approval, such
17rules shall enable a recipient to temporarily acquire and use
18alternative or substitute devices or equipment pending repairs
19or replacements of any device or equipment previously
20authorized for such recipient by the Department.
21Notwithstanding any provision of Section 5-5f to the contrary,
22the Department may, by rule, exempt certain replacement
23wheelchair parts from prior approval and, for wheelchairs,
24wheelchair parts, wheelchair accessories, and related seating
25and positioning items, determine the wholesale price by
26methods other than actual acquisition costs.

 

 

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1    The Department shall require, by rule, all providers of
2durable medical equipment to be accredited by an accreditation
3organization approved by the federal Centers for Medicare and
4Medicaid Services and recognized by the Department in order to
5bill the Department for providing durable medical equipment to
6recipients. No later than 15 months after the effective date
7of the rule adopted pursuant to this paragraph, all providers
8must meet the accreditation requirement.
9    In order to promote environmental responsibility, meet the
10needs of recipients and enrollees, and achieve significant
11cost savings, the Department, or a managed care organization
12under contract with the Department, may provide recipients or
13managed care enrollees who have a prescription or Certificate
14of Medical Necessity access to refurbished durable medical
15equipment under this Section (excluding prosthetic and
16orthotic devices as defined in the Orthotics, Prosthetics, and
17Pedorthics Practice Act and complex rehabilitation technology
18products and associated services) through the State's
19assistive technology program's reutilization program, using
20staff with the Assistive Technology Professional (ATP)
21Certification if the refurbished durable medical equipment:
22(i) is available; (ii) is less expensive, including shipping
23costs, than new durable medical equipment of the same type;
24(iii) is able to withstand at least 3 years of use; (iv) is
25cleaned, disinfected, sterilized, and safe in accordance with
26federal Food and Drug Administration regulations and guidance

 

 

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1governing the reprocessing of medical devices in health care
2settings; and (v) equally meets the needs of the recipient or
3enrollee. The reutilization program shall confirm that the
4recipient or enrollee is not already in receipt of the same or
5similar equipment from another service provider, and that the
6refurbished durable medical equipment equally meets the needs
7of the recipient or enrollee. Nothing in this paragraph shall
8be construed to limit recipient or enrollee choice to obtain
9new durable medical equipment or place any additional prior
10authorization conditions on enrollees of managed care
11organizations.
12    The Department shall execute, relative to the nursing home
13prescreening project, written inter-agency agreements with the
14Department of Human Services and the Department on Aging, to
15effect the following: (i) intake procedures and common
16eligibility criteria for those persons who are receiving
17non-institutional services; and (ii) the establishment and
18development of non-institutional services in areas of the
19State where they are not currently available or are
20undeveloped; and (iii) notwithstanding any other provision of
21law, subject to federal approval, on and after July 1, 2012, an
22increase in the determination of need (DON) scores from 29 to
2337 for applicants for institutional and home and
24community-based long term care; if and only if federal
25approval is not granted, the Department may, in conjunction
26with other affected agencies, implement utilization controls

 

 

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1or changes in benefit packages to effectuate a similar savings
2amount for this population; and (iv) no later than July 1,
32013, minimum level of care eligibility criteria for
4institutional and home and community-based long term care; and
5(v) no later than October 1, 2013, establish procedures to
6permit long term care providers access to eligibility scores
7for individuals with an admission date who are seeking or
8receiving services from the long term care provider. In order
9to select the minimum level of care eligibility criteria, the
10Governor shall establish a workgroup that includes affected
11agency representatives and stakeholders representing the
12institutional and home and community-based long term care
13interests. This Section shall not restrict the Department from
14implementing lower level of care eligibility criteria for
15community-based services in circumstances where federal
16approval has been granted.
17    The Illinois Department shall develop and operate, in
18cooperation with other State Departments and agencies and in
19compliance with applicable federal laws and regulations,
20appropriate and effective systems of health care evaluation
21and programs for monitoring of utilization of health care
22services and facilities, as it affects persons eligible for
23medical assistance under this Code.
24    The Illinois Department shall report annually to the
25General Assembly, no later than the second Friday in April of
261979 and each year thereafter, in regard to:

 

 

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1        (a) actual statistics and trends in utilization of
2    medical services by public aid recipients;
3        (b) actual statistics and trends in the provision of
4    the various medical services by medical vendors;
5        (c) current rate structures and proposed changes in
6    those rate structures for the various medical vendors; and
7        (d) efforts at utilization review and control by the
8    Illinois Department.
9    The period covered by each report shall be the 3 years
10ending on the June 30 prior to the report. The report shall
11include suggested legislation for consideration by the General
12Assembly. The requirement for reporting to the General
13Assembly shall be satisfied by filing copies of the report as
14required by Section 3.1 of the General Assembly Organization
15Act, and filing such additional copies with the State
16Government Report Distribution Center for the General Assembly
17as is required under paragraph (t) of Section 7 of the State
18Library Act.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25    On and after July 1, 2012, the Department shall reduce any
26rate of reimbursement for services or other payments or alter

 

 

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1any methodologies authorized by this Code to reduce any rate
2of reimbursement for services or other payments in accordance
3with Section 5-5e.
4    Because kidney transplantation can be an appropriate,
5cost-effective alternative to renal dialysis when medically
6necessary and notwithstanding the provisions of Section 1-11
7of this Code, beginning October 1, 2014, the Department shall
8cover kidney transplantation for noncitizens with end-stage
9renal disease who are not eligible for comprehensive medical
10benefits, who meet the residency requirements of Section 5-3
11of this Code, and who would otherwise meet the financial
12requirements of the appropriate class of eligible persons
13under Section 5-2 of this Code. To qualify for coverage of
14kidney transplantation, such person must be receiving
15emergency renal dialysis services covered by the Department.
16Providers under this Section shall be prior approved and
17certified by the Department to perform kidney transplantation
18and the services under this Section shall be limited to
19services associated with kidney transplantation.
20    Notwithstanding any other provision of this Code to the
21contrary, on or after July 1, 2015, all FDA approved forms of
22medication assisted treatment prescribed for the treatment of
23alcohol dependence or treatment of opioid dependence shall be
24covered under both fee-for-service fee for service and managed
25care medical assistance programs for persons who are otherwise
26eligible for medical assistance under this Article and shall

 

 

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

 

 

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1transmitted infection screening, treatment for sexually
2transmitted infections, medical monitoring, assorted labs, and
3counseling to reduce the likelihood of HIV infection among
4individuals who are not infected with HIV but who are at high
5risk of HIV infection.
6    A federally qualified health center, as defined in Section
71905(l)(2)(B) of the federal Social Security Act, shall be
8reimbursed by the Department in accordance with the federally
9qualified health center's encounter rate for services provided
10to medical assistance recipients that are performed by a
11dental hygienist, as defined under the Illinois Dental
12Practice Act, working under the general supervision of a
13dentist and employed by a federally qualified health center.
14    Within 90 days after October 8, 2021 (the effective date
15of Public Act 102-665), the Department shall seek federal
16approval of a State Plan amendment to expand coverage for
17family planning services that includes presumptive eligibility
18to individuals whose income is at or below 208% of the federal
19poverty level. Coverage under this Section shall be effective
20beginning no later than December 1, 2022.
21    Subject to approval by the federal Centers for Medicare
22and Medicaid Services of a Title XIX State Plan amendment
23electing the Program of All-Inclusive Care for the Elderly
24(PACE) as a State Medicaid option, as provided for by Subtitle
25I (commencing with Section 4801) of Title IV of the Balanced
26Budget Act of 1997 (Public Law 105-33) and Part 460

 

 

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1(commencing with Section 460.2) of Subchapter E of Title 42 of
2the Code of Federal Regulations, PACE program services shall
3become a covered benefit of the medical assistance program,
4subject to criteria established in accordance with all
5applicable laws.
6    Notwithstanding any other provision of this Code,
7community-based pediatric palliative care from a trained
8interdisciplinary team shall be covered under the medical
9assistance program as provided in Section 15 of the Pediatric
10Palliative Care Act.
11    Notwithstanding any other provision of this Code, within
1212 months after June 2, 2022 (the effective date of Public Act
13102-1037) and subject to federal approval, acupuncture
14services performed by an acupuncturist licensed under the
15Acupuncture Practice Act who is acting within the scope of his
16or her license shall be covered under the medical assistance
17program. The Department shall apply for any federal waiver or
18State Plan amendment, if required, to implement this
19paragraph. The Department may adopt any rules, including
20standards and criteria, necessary to implement this paragraph.
21    Notwithstanding any other provision of this Code, the
22medical assistance program shall, subject to appropriation and
23federal approval, reimburse hospitals for costs associated
24with a newborn screening test for the presence of
25metachromatic leukodystrophy, as required under the Newborn
26Metabolic Screening Act, at a rate not less than the fee

 

 

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1charged by the Department of Public Health. The Department
2shall seek federal approval before the implementation of the
3newborn screening test fees by the Department of Public
4Health.
5    Notwithstanding any other provision of this Code,
6beginning on January 1, 2024, subject to federal approval,
7cognitive assessment and care planning services provided to a
8person who experiences signs or symptoms of cognitive
9impairment, as defined by the Diagnostic and Statistical
10Manual of Mental Disorders, Fifth Edition, shall be covered
11under the medical assistance program for persons who are
12otherwise eligible for medical assistance under this Article.
13    Notwithstanding any other provision of this Code,
14medically necessary reconstructive services that are intended
15to restore physical appearance shall be covered under the
16medical assistance program for persons who are otherwise
17eligible for medical assistance under this Article. As used in
18this paragraph, "reconstructive services" means treatments
19performed on structures of the body damaged by trauma to
20restore physical appearance.
21(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
22102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2355, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
24eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
25102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
265-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;

 

 

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1102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
21-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
3103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
41-1-24; revised 12-15-23.)
 
5    Section 99. Effective date. This Act takes effect January
61, 2026.