(215 ILCS 5/356z.61)

(Text of Section from P.A. 103-1)

Sec. 356z.61. Coverage of pharmacy testing, screening, vaccinations, and treatment. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for health care or patient care services provided by a pharmacist if:

(1) the pharmacist meets the requirements and scope of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the Pharmacy Practice Act;

(2) the health plan provides coverage for the same service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;

(3) the pharmacist is included in the health benefit plan's network of participating providers; and

(4) reimbursement has been successfully negotiated in good faith between the pharmacist and the health plan.

(Source: P.A. 103-1, eff. 4-27-23.)

(Text of Section from P.A. 103-84)

Sec. 356z.61. Coverage for liver disease screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at high risk for liver disease, including liver ultrasounds and alpha-fetoprotein blood tests every 6 months, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this Section does not apply to coverage of liver disease screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(Source: P.A. 103-84, eff. 1-1-24.)

(Text of Section from P.A. 103-91)

Sec. 356z.61. Coverage for compression sleeves. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for compression sleeves that is medically necessary for the enrollee to prevent or mitigate lymphedema.

(Source: P.A. 103-91, eff. 1-1-24.)

(Text of Section from P.A. 103-123)

Sec. 356z.61. Coverage for reconstructive services.

(a) As used in this Section, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance.

(b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 may not deny coverage for medically necessary reconstructive services that are intended to restore physical appearance.

(Source: P.A. 103-123, eff. 1-1-24.)

(Text of Section from P.A. 103-325)

Sec. 356z.61. Proton beam therapy.

(a) As used in this Section:

"Medically necessary" has the meaning given to that term in the Prior Authorization Reform Act.

"Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells.

"Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.

(b) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage for the treatment of cancer shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for the coverage of any other form of radiation therapy treatment.

(c) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage or benefits to any resident of this State for radiation oncology shall include coverage or benefits for medically necessary proton beam therapy for the treatment of cancer.

(Source: P.A. 103-325, eff. 1-1-24.)

(Text of Section from P.A. 103-420)

Sec. 356z.61. Coverage of prescription estrogen.

(a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 and that provides coverage for prescription drugs shall include coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary.

(b) If a particular vaginal estrogen product or its therapeutic equivalent version approved by the United States Food and Drug Administration is determined to be medically necessary, the issuer must cover that service or item pursuant to the cost-sharing requirement contained in subsection (c).

(c) A policy subject to this Section shall not impose a deductible, copayment, or any other cost sharing requirement that exceeds any deductible, coinsurance, copayment, or any other cost-sharing requirement imposed on any prescription drug authorized for the treatment of erectile dysfunction covered by the policy; except that this subsection does not apply to coverage of vaginal estrogen to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(d) As used in this Section, "therapeutic equivalent version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.

(Source: P.A. 103-420, eff. 1-1-24.)

(Text of Section from P.A. 103-445)

Sec. 356z.61. Home saliva cancer screening.

(a) As used in this Section, "home saliva cancer screening" means an outpatient test that utilizes an individual's saliva to detect biomarkers for early-stage cancer.

(b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2025 shall cover a medically necessary home saliva cancer screening every 24 months if the patient:

(1) is asymptomatic and at high risk for the disease being tested for; or

(2) demonstrates symptoms of the disease being tested for at a physical exam.

(Source: P.A. 103-445, eff. 1-1-24.)

(Text of Section from P.A. 103-458)

Sec. 356z.61. Coverage for children with neuromuscular, neurological, or cognitive impairment. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children who have been clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.

(Source: P.A. 103-458, eff. 1-1-24.)

(Text of Section from P.A. 103-535)

Sec. 356z.61. Coverage of no-cost mental health prevention and wellness visits.

(a) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for one annual mental health prevention and wellness visit for children and for adults.

(b) Mental health prevention and wellness visits shall include any age-appropriate screening recommended by the United States Preventive Services Task Force or by the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents for purposes of identifying a mental health issue, condition, or disorder; discussing mental health symptoms that might be present, including symptoms of a previously diagnosed mental health condition or disorder; performing an evaluation of adverse childhood experiences; and discussing mental health and wellness.

(c) A mental health prevention and wellness visit shall be covered for up to 60 minutes and may be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor.

(d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for mental health prevention and wellness visits. The cost-sharing prohibition in this subsection (d) does not apply to coverage of mental health prevention and wellness visits to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(e) A mental health prevention and wellness visit shall be in addition to an annual physical examination and shall not replace a well-child visit or a general health or medical visit.

(f) A mental health prevention and wellness visit shall be reimbursed through the following American Medical Association current procedural terminology codes and at the same rate that current procedural terminology codes are reimbursed for the provision of other medical care: 99381-99387 and 99391-99397. The Department shall update the current procedural terminology codes through adoption of rules if the codes listed in this subsection are altered, amended, changed, deleted, or supplemented.

(g) Reimbursement of any of the current procedural terminology codes listed in this Section shall comply with the following:

(1) reimbursement may be adjusted for payment of claims that are billed by a nonphysician clinician so long as the methodology to determine the adjustments are comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR 146.136(c)(4); and

(2) for a mental health prevention and wellness visit and for a service other than a mental health prevention and wellness visit, reimbursement shall not be denied if they occur on the same date by the same provider and the provider is a primary care provider.

(h) A mental health prevention and wellness visit may be incorporated into and reimbursed within any type of integrated primary care service delivery method, including, but not limited to, a psychiatric collaborative care model as provided for under this Code.

(i) The Department shall adopt any rules necessary to implement this Section by no later than October 31, 2024.

(Source: P.A. 103-535, eff. 8-11-23.)