Sen. Cristina Castro

Filed: 4/9/2021

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 967

2    AMENDMENT NO. ______. Amend Senate Bill 967 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. This Act may be referred to as the Improving
5Health Care for Pregnant and Postpartum Individuals Act.
 
6    Section 5. The State Employees Group Insurance Act of 1971
7is amended by changing Section 6.11 as follows:
 
8    (5 ILCS 375/6.11)
9    Sec. 6.11. Required health benefits; Illinois Insurance
10Code requirements. The program of health benefits shall
11provide the post-mastectomy care benefits required to be
12covered by a policy of accident and health insurance under
13Section 356t of the Illinois Insurance Code. The program of
14health benefits shall provide the coverage required under
15Sections 356g, 356g.5, 356g.5-1, 356m, 356u, 356w, 356x,

 

 

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1356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
2356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
3356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
4356z.36, 356z.40, and 356z.41 of the Illinois Insurance Code.
5The program of health benefits must comply with Sections
6155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article
7XXXIIB of the Illinois Insurance Code. The Department of
8Insurance shall enforce the requirements of this Section with
9respect to Sections 370c and 370c.1 of the Illinois Insurance
10Code; all other requirements of this Section shall be enforced
11by the Department of Central Management Services.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
19100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
201-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13,
21eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
22101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
231-1-21.)
 
24    Section 10. The Department of Human Services Act is
25amended by adding Section 10-23 as follows:
 

 

 

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1    (20 ILCS 1305/10-23 new)
2    Sec. 10-23. High-risk pregnant or postpartum individuals.
3The Department shall expand and update its maternal child
4health programs to serve any pregnant or postpartum woman
5identified as high-risk by the individual's primary care
6provider or hospital according to standards developed by the
7Department of Public Health under Section 3 of the
8Developmental Disability Prevention Act. The services shall be
9provided by registered nurses, licensed social workers, or
10other staff with behavioral health or medical training, as
11approved by the Department. The persons providing the services
12may collaborate with other providers, including, but not
13limited to, obstetricians, gynecologists, or pediatricians,
14when providing services to a patient.
 
15    Section 15. The Department of Public Health Powers and
16Duties Law of the Civil Administrative Code of Illinois is
17amended by renumbering and changing Section 2310-223, as added
18by Public Act 101-390, and by adding Section 2310-470 as
19follows:
 
20    (20 ILCS 2310/2310-222)
21    Sec. 2310-222 2310-223. Obstetric hemorrhage and
22hypertension training.
23    (a) As used in this Section, "birthing facility" means (1)

 

 

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1a hospital, as defined in the Hospital Licensing Act, with
2more than one licensed obstetric bed or a neonatal intensive
3care unit; (2) a hospital operated by a State university; or
4(3) a birth center, as defined in the Alternative Health Care
5Delivery Act.
6    (b) The Department shall ensure that all birthing
7facilities conduct continuing education yearly for providers
8and staff of obstetric medicine and of the emergency
9department and other staff that may care for pregnant or
10postpartum women. The continuing education shall include
11yearly educational modules regarding management of severe
12maternal hypertension and obstetric hemorrhage and other
13leading causes of maternal mortality for units that care for
14pregnant or postpartum women. Birthing facilities must
15demonstrate compliance with these education and training
16requirements.
17    (c) The Department shall collaborate with the Illinois
18Perinatal Quality Collaborative or its successor organization
19to develop an initiative to improve birth equity and reduce
20peripartum racial and ethnic disparities. The Department shall
21ensure that the initiative includes the development of best
22practices for implicit bias training and education in cultural
23competency to be used by birthing facilities in interactions
24between patients and providers. In developing the initiative,
25the Illinois Perinatal Quality Collaborative or its successor
26organization shall consider existing programs, such as the

 

 

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1Alliance for Innovation on Maternal Health and the California
2Maternal Quality Collaborative's pilot work on improving birth
3equity. The Department shall support the initiation of a
4statewide perinatal quality improvement initiative in
5collaboration with birthing facilities to implement strategies
6to reduce peripartum racial and ethnic disparities and to
7address implicit bias in the health care system.
8    (d) The Department, in consultation with the Illinois
9Perinatal Quality Collaborative Maternal Mortality Review
10Committee, shall make available to all birthing facilities
11best practices for timely identification of all pregnant and
12postpartum women in the emergency department and for
13appropriate and timely consultation of an obstetric provider
14to provide input on management and follow-up. Birthing
15facilities may use telemedicine for the consultation.
16    (e) The Department may adopt rules for the purpose of
17implementing this Section.
18(Source: P.A. 101-390, eff. 1-1-20; revised 10-7-19.)
 
19    (20 ILCS 2310/2310-470 new)
20    Sec. 2310-470. High Risk Infant Follow-up. The Department,
21in collaboration with the Department of Human Services, the
22Department of Healthcare and Family Services, and other key
23providers of maternal child health services, shall revise or
24add to the rules of the Maternal and Child Health Services Code
25(77 Ill. Adm. Code 630) that govern the High Risk Infant

 

 

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1Follow-up, using current scientific and national and State
2outcomes data, to expand existing services to improve both
3maternal and infant outcomes overall and to reduce racial
4disparities in outcomes and services provided. The rules shall
5be revised or adopted on or before June 1, 2022.
 
6    Section 20. The Counties Code is amended by changing
7Section 5-1069.3 as follows:
 
8    (55 ILCS 5/5-1069.3)
9    Sec. 5-1069.3. Required health benefits. If a county,
10including a home rule county, is a self-insurer for purposes
11of providing health insurance coverage for its employees, the
12coverage shall include coverage for the post-mastectomy care
13benefits required to be covered by a policy of accident and
14health insurance under Section 356t and the coverage required
15under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
16356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
17356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
18356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
19the Illinois Insurance Code. The coverage shall comply with
20Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
21Insurance Code. The Department of Insurance shall enforce the
22requirements of this Section. The requirement that health
23benefits be covered as provided in this Section is an
24exclusive power and function of the State and is a denial and

 

 

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1limitation under Article VII, Section 6, subsection (h) of the
2Illinois Constitution. A home rule county to which this
3Section applies must comply with every provision of this
4Section.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
12100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
131-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
14eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
15101-625, eff. 1-1-21.)
 
16    Section 25. The Illinois Municipal Code is amended by
17changing Section 10-4-2.3 as follows:
 
18    (65 ILCS 5/10-4-2.3)
19    Sec. 10-4-2.3. Required health benefits. If a
20municipality, including a home rule municipality, is a
21self-insurer for purposes of providing health insurance
22coverage for its employees, the coverage shall include
23coverage for the post-mastectomy care benefits required to be
24covered by a policy of accident and health insurance under

 

 

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1Section 356t and the coverage required under Sections 356g,
2356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9,
3356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
4356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
5356z.36, 356z.40, and 356z.41 of the Illinois Insurance Code.
6The coverage shall comply with Sections 155.22a, 355b,
7356z.19, and 370c of the Illinois Insurance Code. The
8Department of Insurance shall enforce the requirements of this
9Section. The requirement that health benefits be covered as
10provided in this is an exclusive power and function of the
11State and is a denial and limitation under Article VII,
12Section 6, subsection (h) of the Illinois Constitution. A home
13rule municipality to which this Section applies must comply
14with every provision of this Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
22100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
231-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
24eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
25101-625, eff. 1-1-21.)
 

 

 

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1    Section 30. The School Code is amended by changing Section
210-22.3f as follows:
 
3    (105 ILCS 5/10-22.3f)
4    Sec. 10-22.3f. Required health benefits. Insurance
5protection and benefits for employees shall provide the
6post-mastectomy care benefits required to be covered by a
7policy of accident and health insurance under Section 356t and
8the coverage required under Sections 356g, 356g.5, 356g.5-1,
9356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
10356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
11356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
12the Illinois Insurance Code. Insurance policies shall comply
13with Section 356z.19 of the Illinois Insurance Code. The
14coverage shall comply with Sections 155.22a, 355b, and 370c of
15the Illinois Insurance Code. The Department of Insurance shall
16enforce the requirements of this Section.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
24100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
251-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,

 

 

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1eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
2101-625, eff. 1-1-21.)
 
3    Section 35. The University of Illinois Hospital Act is
4amended by adding Section 8e as follows:
 
5    (110 ILCS 330/8e new)
6    Sec. 8e. Written protocol; pregnant and postpartum
7patients. If the University of Illinois Hospital provides
8emergency or obstetric services, the University of Illinois
9Hospital shall implement a written protocol that describes the
10procedures for identifying pregnant and postpartum patients,
11assessing pregnant and postpartum patients for common
12pregnancy or postpartum complications, treating common
13pregnancy or postpartum complications, which may include, but
14are not limited to, the use of hemorrhage emergency carts, and
15consulting with an obstetric provider about pregnant and
16postpartum patient care in accordance with current practice
17guidelines established by the American College of
18Obstetricians and Gynecologists. The protocol must be
19consistently applied across University of Illinois Hospital
20departments.
 
21    Section 40. The Hospital Licensing Act is amended by
22adding Section 11.1b as follows:
 

 

 

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1    (210 ILCS 85/11.1b new)
2    Sec. 11.1b. Written protocol; pregnant and postpartum
3patients. A hospital licensed under this Act that provides
4emergency or obstetric services shall implement a written
5protocol that describes the procedures for identifying
6pregnant and postpartum patients, assessing pregnant and
7postpartum patients for common pregnancy or postpartum
8complications, treating common pregnancy or postpartum
9complications, which may include, but are not limited to, the
10use of hemorrhage emergency carts, and consulting with an
11obstetric provider about pregnant and postpartum patient care
12in accordance with current practice guidelines established by
13the American College of Obstetricians and Gynecologists. The
14protocol must be consistently applied across the hospital's
15departments.
 
16    Section 45. The Illinois Insurance Code is amended by
17adding Sections 356z.4b and 356z.40 as follows:
 
18    (215 ILCS 5/356z.4b new)
19    Sec. 356z.4b. Billing for long-acting reversible
20contraceptives.
21    (a) In this Section, "long-acting reversible contraceptive
22device" means any intrauterine device or contraceptive
23implant.
24    (b) Any group health insurance policy, individual health

 

 

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1policy, group policy of accident and health insurance, group
2health benefit plan, or qualified health plan that is offered
3through the health insurance marketplace, a small employer
4group health plan, or a large employer group health plan that
5is amended, delivered, issued, or renewed on or after the
6effective date of this amendatory Act of the 102nd General
7Assembly shall allow hospitals separate reimbursement for a
8long-acting reversible contraceptive device provided
9immediately postpartum in the inpatient hospital setting
10before hospital discharge. The payment shall be made in
11addition to a bundled or Diagnostic Related Group
12reimbursement for labor and delivery.
 
13    (215 ILCS 5/356z.40 new)
14    Sec. 356z.40. Pregnancy and postpartum coverage.
15    (a) A group health insurance policy, individual health
16policy, group policy of accident and health insurance, group
17health benefit plan, qualified health plan that is offered
18through the health insurance marketplace, small employer group
19health plan, or large employer group health plan that is
20amended, delivered, issued, or renewed on or after the
21effective date of this amendatory Act of the 102nd General
22Assembly shall provide coverage for medically necessary
23treatment for postpartum complications, including, but not
24limited to, infection, depression, and hemorrhaging, up to one
25year after the individual has given birth to a child as set

 

 

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1forth in this Section and consistent with other Sections of
2this Code, including, but not limited to, Sections 370c and
3370c.1. The coverage under this Section shall be subject to
4other general exclusions, limitations, and financial
5requirements of the policy, including coordination of
6benefits, participating provider requirements, and utilization
7review of health care services, including review of medical
8necessity, case management, experimental and investigational
9treatments, managed care provisions, and other terms and
10conditions.
11    (b) A group health insurance policy, individual health
12policy, group policy of accident and health insurance, group
13health benefit plan, qualified health plan that is offered
14through the health insurance marketplace, small employer group
15health plan, or large employer group health plan that is
16amended, delivered, issued, or renewed on or after the
17effective date of this amendatory Act of the 102nd General
18Assembly shall provide coverage for medically necessary
19treatment of a mental, emotional, nervous, or substance use
20disorder or condition at in-network facilities for a pregnant
21or postpartum individual up to one year after giving birth to a
22child consistent with the requirements set forth in this
23Section and in Sections 370c and 370c.1 of this Code. The
24services for the treatment of a mental, emotional, nervous, or
25substance use disorder or condition shall be prescribed or
26ordered by a licensed physician, licensed psychologist,

 

 

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1licensed psychiatrist, or licensed advanced practice
2registered nurse and provided by licensed health care
3professionals or licensed or certified mental, emotional,
4nervous, or substance use disorder or condition providers in
5licensed, certified, or otherwise State-approved facilities.
6    As used in this subsection (b), "provider" includes
7licensed physicians, licensed psychologists, licensed
8psychiatrists, licensed advanced practice registered nurses,
9and licensed and certified mental, emotional, nervous, and
10substance use disorder and condition providers.
11    Benefits under this subsection (b) shall be as follows:
12        (1) The benefits provided for inpatient and outpatient
13    services for the treatment of a mental, emotional,
14    nervous, or substance use disorder or condition related to
15    pregnancy or postpartum complications shall be provided if
16    determined to be medically necessary, consistent with the
17    requirements of Sections 370c and 370c.1 of this Code. The
18    facility or provider shall notify the insurer of both the
19    admission and the initial treatment plan within 48 hours
20    after admission or initiation of treatment. Nothing in
21    this Section shall prevent an insurer from applying
22    concurrent and post-service utilization review of health
23    care services, including review of medical necessity, case
24    management, experimental and investigational treatments,
25    managed care provisions, and other terms and conditions of
26    the insurance policy.

 

 

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1        (2) The benefits for the first 48 hours of initiation
2    of services for an inpatient admission,
3    detoxification/withdrawal management program, or partial
4    hospitalization admission for the treatment of a mental,
5    emotional, nervous, or substance use disorder or condition
6    related to pregnancy or postpartum complications shall be
7    provided without post-service or concurrent review of
8    medical necessity, as the medical necessity for the first
9    48 hours of such services shall be determined solely by
10    the covered pregnant or postpartum individual's provider.
11    Nothing in this Section shall prevent an insurer from
12    applying concurrent and post-service utilization review,
13    including the review of medical necessity, case
14    management, experimental and investigational treatments,
15    managed care provisions, and other terms and conditions of
16    the insurance policy, of any inpatient admission,
17    detoxification/withdrawal management program admission,
18    or partial hospitalization admission services for the
19    treatment of a mental, emotional, nervous, or substance
20    use disorder or condition related to pregnancy or
21    postpartum complications received 48 hours after the
22    initiation of such services. If an insurer determines that
23    the services are no longer medically necessary, then the
24    covered person shall have the right to external review
25    pursuant to the requirements of the Health Carrier
26    External Review Act.

 

 

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1        (3) If an insurer determines that continued inpatient
2    care, detoxification/withdrawal management, partial
3    hospitalization, intensive outpatient treatment, or
4    outpatient treatment in a facility is no longer medically
5    necessary, the insurer shall, within 24 hours, provide
6    written notice to the covered pregnant or postpartum
7    individual and the covered pregnant or postpartum
8    individual's provider of its decision and the right to
9    file an expedited internal appeal of the determination.
10    The insurer shall review and make a determination with
11    respect to the internal appeal within 24 hours and
12    communicate such determination to the covered pregnant or
13    postpartum individual and the covered pregnant or
14    postpartum individual's provider. If the determination is
15    to uphold the denial, the covered pregnant or postpartum
16    individual and the covered pregnant or postpartum
17    individual's provider have the right to file an expedited
18    external appeal. An independent utilization review
19    organization shall make a determination within 72 hours.
20    If the insurer's determination is upheld and it is
21    determined continued inpatient care,
22    detoxification/withdrawal management, partial
23    hospitalization, intensive outpatient treatment, or
24    outpatient treatment is not medically necessary, the
25    insurer shall remain responsible for providing benefits
26    for the inpatient care, detoxification/withdrawal

 

 

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1    management, partial hospitalization, intensive outpatient
2    treatment, or outpatient treatment through the day
3    following the date the determination is made, and the
4    covered pregnant or postpartum individual shall only be
5    responsible for any applicable copayment, deductible, and
6    coinsurance for the stay through that date as applicable
7    under the policy. The covered pregnant or postpartum
8    individual shall not be discharged or released from the
9    inpatient facility, detoxification/withdrawal management,
10    partial hospitalization, intensive outpatient treatment,
11    or outpatient treatment until all internal appeals and
12    independent utilization review organization appeals are
13    exhausted. A decision to reverse an adverse determination
14    shall comply with the Health Carrier External Review Act.
15        (4) Except as otherwise stated in this subsection (b),
16    the benefits and cost-sharing shall be provided to the
17    same extent as for any other medical condition covered
18    under the policy.
19        (5) The benefits required by this subsection (b) are
20    to be provided to all covered pregnant or postpartum
21    individuals with a diagnosis of a mental, emotional,
22    nervous, or substance use disorder or condition. The
23    presence of additional related or unrelated diagnoses
24    shall not be a basis to reduce or deny the benefits
25    required by this subsection (b).
26    (c) A group health insurance policy, individual health

 

 

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1policy, group policy of accident and health insurance, group
2health benefit plan, qualified health plan that is offered
3through the health insurance marketplace, small employer group
4health plan, or large employer group health plan that is
5amended, delivered, issued, executed, or renewed in this State
6or approved for issuance or renewal in this State on or after
7the effective date of this amendatory Act of the 102nd General
8Assembly shall provide coverage for case management and
9outreach for a postpartum individual who had a high-risk
10pregnancy. The coverage under this subsection (c) shall take
11into consideration the cultural differences of the covered
12postpartum individual in case coordination. As used in this
13subsection (c), "high-risk pregnancy" means a pregnancy in
14which the pregnant or postpartum individual or baby is at an
15increased risk for poor health or complications during
16pregnancy or childbirth.
 
17    Section 50. The Health Maintenance Organization Act is
18amended by changing Section 5-3 as follows:
 
19    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
20    Sec. 5-3. Insurance Code provisions.
21    (a) Health Maintenance Organizations shall be subject to
22the provisions of Sections 133, 134, 136, 137, 139, 140,
23141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
24154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,

 

 

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1355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
2356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
3356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
4356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
5356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.40,
6356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
7368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
8408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
9(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
10XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois
11Insurance Code.
12    (b) For purposes of the Illinois Insurance Code, except
13for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
14Health Maintenance Organizations in the following categories
15are deemed to be "domestic companies":
16        (1) a corporation authorized under the Dental Service
17    Plan Act or the Voluntary Health Services Plans Act;
18        (2) a corporation organized under the laws of this
19    State; or
20        (3) a corporation organized under the laws of another
21    state, 30% or more of the enrollees of which are residents
22    of this State, except a corporation subject to
23    substantially the same requirements in its state of
24    organization as is a "domestic company" under Article VIII
25    1/2 of the Illinois Insurance Code.
26    (c) In considering the merger, consolidation, or other

 

 

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1acquisition of control of a Health Maintenance Organization
2pursuant to Article VIII 1/2 of the Illinois Insurance Code,
3        (1) the Director shall give primary consideration to
4    the continuation of benefits to enrollees and the
5    financial conditions of the acquired Health Maintenance
6    Organization after the merger, consolidation, or other
7    acquisition of control takes effect;
8        (2)(i) the criteria specified in subsection (1)(b) of
9    Section 131.8 of the Illinois Insurance Code shall not
10    apply and (ii) the Director, in making his determination
11    with respect to the merger, consolidation, or other
12    acquisition of control, need not take into account the
13    effect on competition of the merger, consolidation, or
14    other acquisition of control;
15        (3) the Director shall have the power to require the
16    following information:
17            (A) certification by an independent actuary of the
18        adequacy of the reserves of the Health Maintenance
19        Organization sought to be acquired;
20            (B) pro forma financial statements reflecting the
21        combined balance sheets of the acquiring company and
22        the Health Maintenance Organization sought to be
23        acquired as of the end of the preceding year and as of
24        a date 90 days prior to the acquisition, as well as pro
25        forma financial statements reflecting projected
26        combined operation for a period of 2 years;

 

 

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1            (C) a pro forma business plan detailing an
2        acquiring party's plans with respect to the operation
3        of the Health Maintenance Organization sought to be
4        acquired for a period of not less than 3 years; and
5            (D) such other information as the Director shall
6        require.
7    (d) The provisions of Article VIII 1/2 of the Illinois
8Insurance Code and this Section 5-3 shall apply to the sale by
9any health maintenance organization of greater than 10% of its
10enrollee population (including without limitation the health
11maintenance organization's right, title, and interest in and
12to its health care certificates).
13    (e) In considering any management contract or service
14agreement subject to Section 141.1 of the Illinois Insurance
15Code, the Director (i) shall, in addition to the criteria
16specified in Section 141.2 of the Illinois Insurance Code,
17take into account the effect of the management contract or
18service agreement on the continuation of benefits to enrollees
19and the financial condition of the health maintenance
20organization to be managed or serviced, and (ii) need not take
21into account the effect of the management contract or service
22agreement on competition.
23    (f) Except for small employer groups as defined in the
24Small Employer Rating, Renewability and Portability Health
25Insurance Act and except for medicare supplement policies as
26defined in Section 363 of the Illinois Insurance Code, a

 

 

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1Health Maintenance Organization may by contract agree with a
2group or other enrollment unit to effect refunds or charge
3additional premiums under the following terms and conditions:
4        (i) the amount of, and other terms and conditions with
5    respect to, the refund or additional premium are set forth
6    in the group or enrollment unit contract agreed in advance
7    of the period for which a refund is to be paid or
8    additional premium is to be charged (which period shall
9    not be less than one year); and
10        (ii) the amount of the refund or additional premium
11    shall not exceed 20% of the Health Maintenance
12    Organization's profitable or unprofitable experience with
13    respect to the group or other enrollment unit for the
14    period (and, for purposes of a refund or additional
15    premium, the profitable or unprofitable experience shall
16    be calculated taking into account a pro rata share of the
17    Health Maintenance Organization's administrative and
18    marketing expenses, but shall not include any refund to be
19    made or additional premium to be paid pursuant to this
20    subsection (f)). The Health Maintenance Organization and
21    the group or enrollment unit may agree that the profitable
22    or unprofitable experience may be calculated taking into
23    account the refund period and the immediately preceding 2
24    plan years.
25    The Health Maintenance Organization shall include a
26statement in the evidence of coverage issued to each enrollee

 

 

10200SB0967sam001- 23 -LRB102 04880 CPF 24550 a

1describing the possibility of a refund or additional premium,
2and upon request of any group or enrollment unit, provide to
3the group or enrollment unit a description of the method used
4to calculate (1) the Health Maintenance Organization's
5profitable experience with respect to the group or enrollment
6unit and the resulting refund to the group or enrollment unit
7or (2) the Health Maintenance Organization's unprofitable
8experience with respect to the group or enrollment unit and
9the resulting additional premium to be paid by the group or
10enrollment unit.
11    In no event shall the Illinois Health Maintenance
12Organization Guaranty Association be liable to pay any
13contractual obligation of an insolvent organization to pay any
14refund authorized under this Section.
15    (g) Rulemaking authority to implement Public Act 95-1045,
16if any, is conditioned on the rules being adopted in
17accordance with all provisions of the Illinois Administrative
18Procedure Act and all rules and procedures of the Joint
19Committee on Administrative Rules; any purported rule not so
20adopted, for whatever reason, is unauthorized.
21(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
22100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
231-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
24eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;
25101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
261-1-20; 101-625, eff. 1-1-21.)
 

 

 

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1    Section 55. The Voluntary Health Services Plans Act is
2amended by changing Section 10 as follows:
 
3    (215 ILCS 165/10)  (from Ch. 32, par. 604)
4    Sec. 10. Application of Insurance Code provisions. Health
5services plan corporations and all persons interested therein
6or dealing therewith shall be subject to the provisions of
7Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
8143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
9356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x,
10356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
11356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
12356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29,
13356z.30, 356z.30a, 356z.32, 356z.33, 356z.40, 356z.41, 364.01,
14367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
15and paragraphs (7) and (15) of Section 367 of the Illinois
16Insurance Code.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
24100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.

 

 

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11-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
2eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
3101-625, eff. 1-1-21.)
 
4    Section 60. The Illinois Public Aid Code is amended by
5changing Sections 5-2, 5-5, and 5-5.24 and by adding Sections
65-18.10 and 5-18.15 as follows:
 
7    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
8    Sec. 5-2. Classes of persons eligible. Medical assistance
9under this Article shall be available to any of the following
10classes of persons in respect to whom a plan for coverage has
11been submitted to the Governor by the Illinois Department and
12approved by him. If changes made in this Section 5-2 require
13federal approval, they shall not take effect until such
14approval has been received:
15        1. Recipients of basic maintenance grants under
16    Articles III and IV.
17        2. Beginning January 1, 2014, persons otherwise
18    eligible for basic maintenance under Article III,
19    excluding any eligibility requirements that are
20    inconsistent with any federal law or federal regulation,
21    as interpreted by the U.S. Department of Health and Human
22    Services, but who fail to qualify thereunder on the basis
23    of need, and who have insufficient income and resources to
24    meet the costs of necessary medical care, including, but

 

 

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1    not limited to, the following:
2            (a) All persons otherwise eligible for basic
3        maintenance under Article III but who fail to qualify
4        under that Article on the basis of need and who meet
5        either of the following requirements:
6                (i) their income, as determined by the
7            Illinois Department in accordance with any federal
8            requirements, is equal to or less than 100% of the
9            federal poverty level; or
10                (ii) their income, after the deduction of
11            costs incurred for medical care and for other
12            types of remedial care, is equal to or less than
13            100% of the federal poverty level.
14            (b) (Blank).
15        3. (Blank).
16        4. Persons not eligible under any of the preceding
17    paragraphs who fall sick, are injured, or die, not having
18    sufficient money, property or other resources to meet the
19    costs of necessary medical care or funeral and burial
20    expenses.
21        5.(a) Beginning January 1, 2020, individuals women
22    during pregnancy and during the 12-month period beginning
23    on the last day of the pregnancy, together with their
24    infants, whose income is at or below 200% of the federal
25    poverty level. Until September 30, 2019, or sooner if the
26    maintenance of effort requirements under the Patient

 

 

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1    Protection and Affordable Care Act are eliminated or may
2    be waived before then, individuals women during pregnancy
3    and during the 12-month period beginning on the last day
4    of the pregnancy, whose countable monthly income, after
5    the deduction of costs incurred for medical care and for
6    other types of remedial care as specified in
7    administrative rule, is equal to or less than the Medical
8    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
9    on April 1, 2013 as set forth in administrative rule.
10        (b) The plan for coverage shall provide ambulatory
11    prenatal care to pregnant individuals women during a
12    presumptive eligibility period and establish an income
13    eligibility standard that is equal to 200% of the federal
14    poverty level, provided that costs incurred for medical
15    care are not taken into account in determining such income
16    eligibility.
17        (c) The Illinois Department may conduct a
18    demonstration in at least one county that will provide
19    medical assistance to pregnant individuals women, together
20    with their infants and children up to one year of age,
21    where the income eligibility standard is set up to 185% of
22    the nonfarm income official poverty line, as defined by
23    the federal Office of Management and Budget. The Illinois
24    Department shall seek and obtain necessary authorization
25    provided under federal law to implement such a
26    demonstration. Such demonstration may establish resource

 

 

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1    standards that are not more restrictive than those
2    established under Article IV of this Code.
3        6. (a) Children younger than age 19 when countable
4    income is at or below 133% of the federal poverty level.
5    Until September 30, 2019, or sooner if the maintenance of
6    effort requirements under the Patient Protection and
7    Affordable Care Act are eliminated or may be waived before
8    then, children younger than age 19 whose countable monthly
9    income, after the deduction of costs incurred for medical
10    care and for other types of remedial care as specified in
11    administrative rule, is equal to or less than the Medical
12    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
13    on April 1, 2013 as set forth in administrative rule.
14        (b) Children and youth who are under temporary custody
15    or guardianship of the Department of Children and Family
16    Services or who receive financial assistance in support of
17    an adoption or guardianship placement from the Department
18    of Children and Family Services.
19        7. (Blank).
20        8. As required under federal law, persons who are
21    eligible for Transitional Medical Assistance as a result
22    of an increase in earnings or child or spousal support
23    received. The plan for coverage for this class of persons
24    shall:
25            (a) extend the medical assistance coverage to the
26        extent required by federal law; and

 

 

10200SB0967sam001- 29 -LRB102 04880 CPF 24550 a

1            (b) offer persons who have initially received 6
2        months of the coverage provided in paragraph (a)
3        above, the option of receiving an additional 6 months
4        of coverage, subject to the following:
5                (i) such coverage shall be pursuant to
6            provisions of the federal Social Security Act;
7                (ii) such coverage shall include all services
8            covered under Illinois' State Medicaid Plan;
9                (iii) no premium shall be charged for such
10            coverage; and
11                (iv) such coverage shall be suspended in the
12            event of a person's failure without good cause to
13            file in a timely fashion reports required for this
14            coverage under the Social Security Act and
15            coverage shall be reinstated upon the filing of
16            such reports if the person remains otherwise
17            eligible.
18        9. Persons with acquired immunodeficiency syndrome
19    (AIDS) or with AIDS-related conditions with respect to
20    whom there has been a determination that but for home or
21    community-based services such individuals would require
22    the level of care provided in an inpatient hospital,
23    skilled nursing facility or intermediate care facility the
24    cost of which is reimbursed under this Article. Assistance
25    shall be provided to such persons to the maximum extent
26    permitted under Title XIX of the Federal Social Security

 

 

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1    Act.
2        10. Participants in the long-term care insurance
3    partnership program established under the Illinois
4    Long-Term Care Partnership Program Act who meet the
5    qualifications for protection of resources described in
6    Section 15 of that Act.
7        11. Persons with disabilities who are employed and
8    eligible for Medicaid, pursuant to Section
9    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
10    subject to federal approval, persons with a medically
11    improved disability who are employed and eligible for
12    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
13    the Social Security Act, as provided by the Illinois
14    Department by rule. In establishing eligibility standards
15    under this paragraph 11, the Department shall, subject to
16    federal approval:
17            (a) set the income eligibility standard at not
18        lower than 350% of the federal poverty level;
19            (b) exempt retirement accounts that the person
20        cannot access without penalty before the age of 59
21        1/2, and medical savings accounts established pursuant
22        to 26 U.S.C. 220;
23            (c) allow non-exempt assets up to $25,000 as to
24        those assets accumulated during periods of eligibility
25        under this paragraph 11; and
26            (d) continue to apply subparagraphs (b) and (c) in

 

 

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1        determining the eligibility of the person under this
2        Article even if the person loses eligibility under
3        this paragraph 11.
4        12. Subject to federal approval, persons who are
5    eligible for medical assistance coverage under applicable
6    provisions of the federal Social Security Act and the
7    federal Breast and Cervical Cancer Prevention and
8    Treatment Act of 2000. Those eligible persons are defined
9    to include, but not be limited to, the following persons:
10            (1) persons who have been screened for breast or
11        cervical cancer under the U.S. Centers for Disease
12        Control and Prevention Breast and Cervical Cancer
13        Program established under Title XV of the federal
14        Public Health Service Services Act in accordance with
15        the requirements of Section 1504 of that Act as
16        administered by the Illinois Department of Public
17        Health; and
18            (2) persons whose screenings under the above
19        program were funded in whole or in part by funds
20        appropriated to the Illinois Department of Public
21        Health for breast or cervical cancer screening.
22        "Medical assistance" under this paragraph 12 shall be
23    identical to the benefits provided under the State's
24    approved plan under Title XIX of the Social Security Act.
25    The Department must request federal approval of the
26    coverage under this paragraph 12 within 30 days after July

 

 

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1    3, 2001 (the effective date of Public Act 92-47) this
2    amendatory Act of the 92nd General Assembly.
3        In addition to the persons who are eligible for
4    medical assistance pursuant to subparagraphs (1) and (2)
5    of this paragraph 12, and to be paid from funds
6    appropriated to the Department for its medical programs,
7    any uninsured person as defined by the Department in rules
8    residing in Illinois who is younger than 65 years of age,
9    who has been screened for breast and cervical cancer in
10    accordance with standards and procedures adopted by the
11    Department of Public Health for screening, and who is
12    referred to the Department by the Department of Public
13    Health as being in need of treatment for breast or
14    cervical cancer is eligible for medical assistance
15    benefits that are consistent with the benefits provided to
16    those persons described in subparagraphs (1) and (2).
17    Medical assistance coverage for the persons who are
18    eligible under the preceding sentence is not dependent on
19    federal approval, but federal moneys may be used to pay
20    for services provided under that coverage upon federal
21    approval.
22        13. Subject to appropriation and to federal approval,
23    persons living with HIV/AIDS who are not otherwise
24    eligible under this Article and who qualify for services
25    covered under Section 5-5.04 as provided by the Illinois
26    Department by rule.

 

 

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1        14. Subject to the availability of funds for this
2    purpose, the Department may provide coverage under this
3    Article to persons who reside in Illinois who are not
4    eligible under any of the preceding paragraphs and who
5    meet the income guidelines of paragraph 2(a) of this
6    Section and (i) have an application for asylum pending
7    before the federal Department of Homeland Security or on
8    appeal before a court of competent jurisdiction and are
9    represented either by counsel or by an advocate accredited
10    by the federal Department of Homeland Security and
11    employed by a not-for-profit organization in regard to
12    that application or appeal, or (ii) are receiving services
13    through a federally funded torture treatment center.
14    Medical coverage under this paragraph 14 may be provided
15    for up to 24 continuous months from the initial
16    eligibility date so long as an individual continues to
17    satisfy the criteria of this paragraph 14. If an
18    individual has an appeal pending regarding an application
19    for asylum before the Department of Homeland Security,
20    eligibility under this paragraph 14 may be extended until
21    a final decision is rendered on the appeal. The Department
22    may adopt rules governing the implementation of this
23    paragraph 14.
24        15. Family Care Eligibility.
25            (a) On and after July 1, 2012, a parent or other
26        caretaker relative who is 19 years of age or older when

 

 

10200SB0967sam001- 34 -LRB102 04880 CPF 24550 a

1        countable income is at or below 133% of the federal
2        poverty level. A person may not spend down to become
3        eligible under this paragraph 15.
4            (b) Eligibility shall be reviewed annually.
5            (c) (Blank).
6            (d) (Blank).
7            (e) (Blank).
8            (f) (Blank).
9            (g) (Blank).
10            (h) (Blank).
11            (i) Following termination of an individual's
12        coverage under this paragraph 15, the individual must
13        be determined eligible before the person can be
14        re-enrolled.
15        16. Subject to appropriation, uninsured persons who
16    are not otherwise eligible under this Section who have
17    been certified and referred by the Department of Public
18    Health as having been screened and found to need
19    diagnostic evaluation or treatment, or both diagnostic
20    evaluation and treatment, for prostate or testicular
21    cancer. For the purposes of this paragraph 16, uninsured
22    persons are those who do not have creditable coverage, as
23    defined under the Health Insurance Portability and
24    Accountability Act, or have otherwise exhausted any
25    insurance benefits they may have had, for prostate or
26    testicular cancer diagnostic evaluation or treatment, or

 

 

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1    both diagnostic evaluation and treatment. To be eligible,
2    a person must furnish a Social Security number. A person's
3    assets are exempt from consideration in determining
4    eligibility under this paragraph 16. Such persons shall be
5    eligible for medical assistance under this paragraph 16
6    for so long as they need treatment for the cancer. A person
7    shall be considered to need treatment if, in the opinion
8    of the person's treating physician, the person requires
9    therapy directed toward cure or palliation of prostate or
10    testicular cancer, including recurrent metastatic cancer
11    that is a known or presumed complication of prostate or
12    testicular cancer and complications resulting from the
13    treatment modalities themselves. Persons who require only
14    routine monitoring services are not considered to need
15    treatment. "Medical assistance" under this paragraph 16
16    shall be identical to the benefits provided under the
17    State's approved plan under Title XIX of the Social
18    Security Act. Notwithstanding any other provision of law,
19    the Department (i) does not have a claim against the
20    estate of a deceased recipient of services under this
21    paragraph 16 and (ii) does not have a lien against any
22    homestead property or other legal or equitable real
23    property interest owned by a recipient of services under
24    this paragraph 16.
25        17. Persons who, pursuant to a waiver approved by the
26    Secretary of the U.S. Department of Health and Human

 

 

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1    Services, are eligible for medical assistance under Title
2    XIX or XXI of the federal Social Security Act.
3    Notwithstanding any other provision of this Code and
4    consistent with the terms of the approved waiver, the
5    Illinois Department, may by rule:
6            (a) Limit the geographic areas in which the waiver
7        program operates.
8            (b) Determine the scope, quantity, duration, and
9        quality, and the rate and method of reimbursement, of
10        the medical services to be provided, which may differ
11        from those for other classes of persons eligible for
12        assistance under this Article.
13            (c) Restrict the persons' freedom in choice of
14        providers.
15        18. Beginning January 1, 2014, persons aged 19 or
16    older, but younger than 65, who are not otherwise eligible
17    for medical assistance under this Section 5-2, who qualify
18    for medical assistance pursuant to 42 U.S.C.
19    1396a(a)(10)(A)(i)(VIII) and applicable federal
20    regulations, and who have income at or below 133% of the
21    federal poverty level plus 5% for the applicable family
22    size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
23    applicable federal regulations. Persons eligible for
24    medical assistance under this paragraph 18 shall receive
25    coverage for the Health Benefits Service Package as that
26    term is defined in subsection (m) of Section 5-1.1 of this

 

 

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1    Code. If Illinois' federal medical assistance percentage
2    (FMAP) is reduced below 90% for persons eligible for
3    medical assistance under this paragraph 18, eligibility
4    under this paragraph 18 shall cease no later than the end
5    of the third month following the month in which the
6    reduction in FMAP takes effect.
7        19. Beginning January 1, 2014, as required under 42
8    U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
9    and younger than age 26 who are not otherwise eligible for
10    medical assistance under paragraphs (1) through (17) of
11    this Section who (i) were in foster care under the
12    responsibility of the State on the date of attaining age
13    18 or on the date of attaining age 21 when a court has
14    continued wardship for good cause as provided in Section
15    2-31 of the Juvenile Court Act of 1987 and (ii) received
16    medical assistance under the Illinois Title XIX State Plan
17    or waiver of such plan while in foster care.
18        20. Beginning January 1, 2018, persons who are
19    foreign-born victims of human trafficking, torture, or
20    other serious crimes as defined in Section 2-19 of this
21    Code and their derivative family members if such persons:
22    (i) reside in Illinois; (ii) are not eligible under any of
23    the preceding paragraphs; (iii) meet the income guidelines
24    of subparagraph (a) of paragraph 2; and (iv) meet the
25    nonfinancial eligibility requirements of Sections 16-2,
26    16-3, and 16-5 of this Code. The Department may extend

 

 

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1    medical assistance for persons who are foreign-born
2    victims of human trafficking, torture, or other serious
3    crimes whose medical assistance would be terminated
4    pursuant to subsection (b) of Section 16-5 if the
5    Department determines that the person, during the year of
6    initial eligibility (1) experienced a health crisis, (2)
7    has been unable, after reasonable attempts, to obtain
8    necessary information from a third party, or (3) has other
9    extenuating circumstances that prevented the person from
10    completing his or her application for status. The
11    Department may adopt any rules necessary to implement the
12    provisions of this paragraph.
13        21. Persons who are not otherwise eligible for medical
14    assistance under this Section who may qualify for medical
15    assistance pursuant to 42 U.S.C.
16    1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
17    duration of any federal or State declared emergency due to
18    COVID-19. Medical assistance to persons eligible for
19    medical assistance solely pursuant to this paragraph 21
20    shall be limited to any in vitro diagnostic product (and
21    the administration of such product) described in 42 U.S.C.
22    1396d(a)(3)(B) on or after March 18, 2020, any visit
23    described in 42 U.S.C. 1396o(a)(2)(G), or any other
24    medical assistance that may be federally authorized for
25    this class of persons. The Department may also cover
26    treatment of COVID-19 for this class of persons, or any

 

 

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1    similar category of uninsured individuals, to the extent
2    authorized under a federally approved 1115 Waiver or other
3    federal authority. Notwithstanding the provisions of
4    Section 1-11 of this Code, due to the nature of the
5    COVID-19 public health emergency, the Department may cover
6    and provide the medical assistance described in this
7    paragraph 21 to noncitizens who would otherwise meet the
8    eligibility requirements for the class of persons
9    described in this paragraph 21 for the duration of the
10    State emergency period.
11    In implementing the provisions of Public Act 96-20, the
12Department is authorized to adopt only those rules necessary,
13including emergency rules. Nothing in Public Act 96-20 permits
14the Department to adopt rules or issue a decision that expands
15eligibility for the FamilyCare Program to a person whose
16income exceeds 185% of the Federal Poverty Level as determined
17from time to time by the U.S. Department of Health and Human
18Services, unless the Department is provided with express
19statutory authority.
20    The eligibility of any such person for medical assistance
21under this Article is not affected by the payment of any grant
22under the Senior Citizens and Persons with Disabilities
23Property Tax Relief Act or any distributions or items of
24income described under subparagraph (X) of paragraph (2) of
25subsection (a) of Section 203 of the Illinois Income Tax Act.
26    The Department shall by rule establish the amounts of

 

 

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1assets to be disregarded in determining eligibility for
2medical assistance, which shall at a minimum equal the amounts
3to be disregarded under the Federal Supplemental Security
4Income Program. The amount of assets of a single person to be
5disregarded shall not be less than $2,000, and the amount of
6assets of a married couple to be disregarded shall not be less
7than $3,000.
8    To the extent permitted under federal law, any person
9found guilty of a second violation of Article VIIIA shall be
10ineligible for medical assistance under this Article, as
11provided in Section 8A-8.
12    The eligibility of any person for medical assistance under
13this Article shall not be affected by the receipt by the person
14of donations or benefits from fundraisers held for the person
15in cases of serious illness, as long as neither the person nor
16members of the person's family have actual control over the
17donations or benefits or the disbursement of the donations or
18benefits.
19    Notwithstanding any other provision of this Code, if the
20United States Supreme Court holds Title II, Subtitle A,
21Section 2001(a) of Public Law 111-148 to be unconstitutional,
22or if a holding of Public Law 111-148 makes Medicaid
23eligibility allowed under Section 2001(a) inoperable, the
24State or a unit of local government shall be prohibited from
25enrolling individuals in the Medical Assistance Program as the
26result of federal approval of a State Medicaid waiver on or

 

 

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1after June 14, 2012 (the effective date of Public Act 97-687)
2this amendatory Act of the 97th General Assembly, and any
3individuals enrolled in the Medical Assistance Program
4pursuant to eligibility permitted as a result of such a State
5Medicaid waiver shall become immediately ineligible.
6    Notwithstanding any other provision of this Code, if an
7Act of Congress that becomes a Public Law eliminates Section
82001(a) of Public Law 111-148, the State or a unit of local
9government shall be prohibited from enrolling individuals in
10the Medical Assistance Program as the result of federal
11approval of a State Medicaid waiver on or after June 14, 2012
12(the effective date of Public Act 97-687) this amendatory Act
13of the 97th General Assembly, and any individuals enrolled in
14the Medical Assistance Program pursuant to eligibility
15permitted as a result of such a State Medicaid waiver shall
16become immediately ineligible.
17    Effective October 1, 2013, the determination of
18eligibility of persons who qualify under paragraphs 5, 6, 8,
1915, 17, and 18 of this Section shall comply with the
20requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
21regulations.
22    The Department of Healthcare and Family Services, the
23Department of Human Services, and the Illinois health
24insurance marketplace shall work cooperatively to assist
25persons who would otherwise lose health benefits as a result
26of changes made under Public Act 98-104 this amendatory Act of

 

 

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1the 98th General Assembly to transition to other health
2insurance coverage.
3(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
4revised 8-24-20.)
 
5    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
6    Sec. 5-5. Medical services. The Illinois Department, by
7rule, shall determine the quantity and quality of and the rate
8of reimbursement for the medical assistance for which payment
9will be authorized, and the medical services to be provided,
10which may include all or part of the following: (1) inpatient
11hospital services; (2) outpatient hospital services; (3) other
12laboratory and X-ray services; (4) skilled nursing home
13services; (5) physicians' services whether furnished in the
14office, the patient's home, a hospital, a skilled nursing
15home, or elsewhere; (6) medical care, or any other type of
16remedial care furnished by licensed practitioners; (7) home
17health care services; (8) private duty nursing service; (9)
18clinic services; (10) dental services, including prevention
19and treatment of periodontal disease and dental caries disease
20for pregnant individuals women, provided by an individual
21licensed to practice dentistry or dental surgery; for purposes
22of this item (10), "dental services" means diagnostic,
23preventive, or corrective procedures provided by or under the
24supervision of a dentist in the practice of his or her
25profession; (11) physical therapy and related services; (12)

 

 

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1prescribed drugs, dentures, and prosthetic devices; and
2eyeglasses prescribed by a physician skilled in the diseases
3of the eye, or by an optometrist, whichever the person may
4select; (13) other diagnostic, screening, preventive, and
5rehabilitative services, including to ensure that the
6individual's need for intervention or treatment of mental
7disorders or substance use disorders or co-occurring mental
8health and substance use disorders is determined using a
9uniform screening, assessment, and evaluation process
10inclusive of criteria, for children and adults; for purposes
11of this item (13), a uniform screening, assessment, and
12evaluation process refers to a process that includes an
13appropriate evaluation and, as warranted, a referral;
14"uniform" does not mean the use of a singular instrument,
15tool, or process that all must utilize; (14) transportation
16and such other expenses as may be necessary; (15) medical
17treatment of sexual assault survivors, as defined in Section
181a of the Sexual Assault Survivors Emergency Treatment Act,
19for injuries sustained as a result of the sexual assault,
20including examinations and laboratory tests to discover
21evidence which may be used in criminal proceedings arising
22from the sexual assault; (16) the diagnosis and treatment of
23sickle cell anemia; and (17) any other medical care, and any
24other type of remedial care recognized under the laws of this
25State. The term "any other type of remedial care" shall
26include nursing care and nursing home service for persons who

 

 

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1rely on treatment by spiritual means alone through prayer for
2healing.
3    Notwithstanding any other provision of this Section, a
4comprehensive tobacco use cessation program that includes
5purchasing prescription drugs or prescription medical devices
6approved by the Food and Drug Administration shall be covered
7under the medical assistance program under this Article for
8persons who are otherwise eligible for assistance under this
9Article.
10    Notwithstanding any other provision of this Code,
11reproductive health care that is otherwise legal in Illinois
12shall be covered under the medical assistance program for
13persons who are otherwise eligible for medical assistance
14under this Article.
15    Notwithstanding any other provision of this Code, the
16Illinois Department may not require, as a condition of payment
17for any laboratory test authorized under this Article, that a
18physician's handwritten signature appear on the laboratory
19test order form. The Illinois Department may, however, impose
20other appropriate requirements regarding laboratory test order
21documentation.
22    Upon receipt of federal approval of an amendment to the
23Illinois Title XIX State Plan for this purpose, the Department
24shall authorize the Chicago Public Schools (CPS) to procure a
25vendor or vendors to manufacture eyeglasses for individuals
26enrolled in a school within the CPS system. CPS shall ensure

 

 

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1that its vendor or vendors are enrolled as providers in the
2medical assistance program and in any capitated Medicaid
3managed care entity (MCE) serving individuals enrolled in a
4school within the CPS system. Under any contract procured
5under this provision, the vendor or vendors must serve only
6individuals enrolled in a school within the CPS system. Claims
7for services provided by CPS's vendor or vendors to recipients
8of benefits in the medical assistance program under this Code,
9the Children's Health Insurance Program, or the Covering ALL
10KIDS Health Insurance Program shall be submitted to the
11Department or the MCE in which the individual is enrolled for
12payment and shall be reimbursed at the Department's or the
13MCE's established rates or rate methodologies for eyeglasses.
14    On and after July 1, 2012, the Department of Healthcare
15and Family Services may provide the following services to
16persons eligible for assistance under this Article who are
17participating in education, training or employment programs
18operated by the Department of Human Services as successor to
19the Department of Public Aid:
20        (1) dental services provided by or under the
21    supervision of a dentist; and
22        (2) eyeglasses prescribed by a physician skilled in
23    the diseases of the eye, or by an optometrist, whichever
24    the person may select.
25    On and after July 1, 2018, the Department of Healthcare
26and Family Services shall provide dental services to any adult

 

 

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1who is otherwise eligible for assistance under the medical
2assistance program. As used in this paragraph, "dental
3services" means diagnostic, preventative, restorative, or
4corrective procedures, including procedures and services for
5the prevention and treatment of periodontal disease and dental
6caries disease, provided by an individual who is licensed to
7practice dentistry or dental surgery or who is under the
8supervision of a dentist in the practice of his or her
9profession.
10    On and after July 1, 2018, targeted dental services, as
11set forth in Exhibit D of the Consent Decree entered by the
12United States District Court for the Northern District of
13Illinois, Eastern Division, in the matter of Memisovski v.
14Maram, Case No. 92 C 1982, that are provided to adults under
15the medical assistance program shall be established at no less
16than the rates set forth in the "New Rate" column in Exhibit D
17of the Consent Decree for targeted dental services that are
18provided to persons under the age of 18 under the medical
19assistance program.
20    Notwithstanding any other provision of this Code and
21subject to federal approval, the Department may adopt rules to
22allow a dentist who is volunteering his or her service at no
23cost to render dental services through an enrolled
24not-for-profit health clinic without the dentist personally
25enrolling as a participating provider in the medical
26assistance program. A not-for-profit health clinic shall

 

 

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1include a public health clinic or Federally Qualified Health
2Center or other enrolled provider, as determined by the
3Department, through which dental services covered under this
4Section are performed. The Department shall establish a
5process for payment of claims for reimbursement for covered
6dental services rendered under this provision.
7    The Illinois Department, by rule, may distinguish and
8classify the medical services to be provided only in
9accordance with the classes of persons designated in Section
105-2.
11    The Department of Healthcare and Family Services must
12provide coverage and reimbursement for amino acid-based
13elemental formulas, regardless of delivery method, for the
14diagnosis and treatment of (i) eosinophilic disorders and (ii)
15short bowel syndrome when the prescribing physician has issued
16a written order stating that the amino acid-based elemental
17formula is medically necessary.
18    The Illinois Department shall authorize the provision of,
19and shall authorize payment for, screening by low-dose
20mammography for the presence of occult breast cancer for
21individuals women 35 years of age or older who are eligible for
22medical assistance under this Article, as follows:
23        (A) A baseline mammogram for individuals women 35 to
24    39 years of age.
25        (B) An annual mammogram for individuals women 40 years
26    of age or older.

 

 

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1        (C) A mammogram at the age and intervals considered
2    medically necessary by the individual's woman's health
3    care provider for individuals women under 40 years of age
4    and having a family history of breast cancer, prior
5    personal history of breast cancer, positive genetic
6    testing, or other risk factors.
7        (D) A comprehensive ultrasound screening and MRI of an
8    entire breast or breasts if a mammogram demonstrates
9    heterogeneous or dense breast tissue or when medically
10    necessary as determined by a physician licensed to
11    practice medicine in all of its branches.
12        (E) A screening MRI when medically necessary, as
13    determined by a physician licensed to practice medicine in
14    all of its branches.
15        (F) A diagnostic mammogram when medically necessary,
16    as determined by a physician licensed to practice medicine
17    in all its branches, advanced practice registered nurse,
18    or physician assistant.
19    The Department shall not impose a deductible, coinsurance,
20copayment, or any other cost-sharing requirement on the
21coverage provided under this paragraph; except that this
22sentence does not apply to coverage of diagnostic mammograms
23to the extent such coverage would disqualify a high-deductible
24health plan from eligibility for a health savings account
25pursuant to Section 223 of the Internal Revenue Code (26
26U.S.C. 223).

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool.
5     For purposes of this Section:
6    "Diagnostic mammogram" means a mammogram obtained using
7diagnostic mammography.
8    "Diagnostic mammography" means a method of screening that
9is designed to evaluate an abnormality in a breast, including
10an abnormality seen or suspected on a screening mammogram or a
11subjective or objective abnormality otherwise detected in the
12breast.
13    "Low-dose mammography" means the x-ray examination of the
14breast using equipment dedicated specifically for mammography,
15including the x-ray tube, filter, compression device, and
16image receptor, with an average radiation exposure delivery of
17less than one rad per breast for 2 views of an average size
18breast. The term also includes digital mammography and
19includes breast tomosynthesis.
20    "Breast tomosynthesis" means a radiologic procedure that
21involves the acquisition of projection images over the
22stationary breast to produce cross-sectional digital
23three-dimensional images of the breast.
24    If, at any time, the Secretary of the United States
25Department of Health and Human Services, or its successor
26agency, promulgates rules or regulations to be published in

 

 

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1the Federal Register or publishes a comment in the Federal
2Register or issues an opinion, guidance, or other action that
3would require the State, pursuant to any provision of the
4Patient Protection and Affordable Care Act (Public Law
5111-148), including, but not limited to, 42 U.S.C.
618031(d)(3)(B) or any successor provision, to defray the cost
7of any coverage for breast tomosynthesis outlined in this
8paragraph, then the requirement that an insurer cover breast
9tomosynthesis is inoperative other than any such coverage
10authorized under Section 1902 of the Social Security Act, 42
11U.S.C. 1396a, and the State shall not assume any obligation
12for the cost of coverage for breast tomosynthesis set forth in
13this paragraph.
14    On and after January 1, 2016, the Department shall ensure
15that all networks of care for adult clients of the Department
16include access to at least one breast imaging Center of
17Imaging Excellence as certified by the American College of
18Radiology.
19    On and after January 1, 2012, providers participating in a
20quality improvement program approved by the Department shall
21be reimbursed for screening and diagnostic mammography at the
22same rate as the Medicare program's rates, including the
23increased reimbursement for digital mammography.
24    The Department shall convene an expert panel including
25representatives of hospitals, free-standing mammography
26facilities, and doctors, including radiologists, to establish

 

 

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1quality standards for mammography.
2    On and after January 1, 2017, providers participating in a
3breast cancer treatment quality improvement program approved
4by the Department shall be reimbursed for breast cancer
5treatment at a rate that is no lower than 95% of the Medicare
6program's rates for the data elements included in the breast
7cancer treatment quality program.
8    The Department shall convene an expert panel, including
9representatives of hospitals, free-standing breast cancer
10treatment centers, breast cancer quality organizations, and
11doctors, including breast surgeons, reconstructive breast
12surgeons, oncologists, and primary care providers to establish
13quality standards for breast cancer treatment.
14    Subject to federal approval, the Department shall
15establish a rate methodology for mammography at federally
16qualified health centers and other encounter-rate clinics.
17These clinics or centers may also collaborate with other
18hospital-based mammography facilities. By January 1, 2016, the
19Department shall report to the General Assembly on the status
20of the provision set forth in this paragraph.
21    The Department shall establish a methodology to remind
22individuals women who are age-appropriate for screening
23mammography, but who have not received a mammogram within the
24previous 18 months, of the importance and benefit of screening
25mammography. The Department shall work with experts in breast
26cancer outreach and patient navigation to optimize these

 

 

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

 

 

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1patients to comprehensive care in a timely fashion. The
2Department shall require all networks of care to include
3access for patients diagnosed with cancer to at least one
4academic commission on cancer-accredited cancer program as an
5in-network covered benefit.
6    On or after July 1, 2022, individuals who are otherwise
7eligible for medical assistance under this Article shall
8receive coverage for perinatal depression screenings for the
912-month period beginning on the last day of their pregnancy.
10Medical assistance coverage under this paragraph shall be
11conditioned on the use of a screening instrument approved by
12the Department.
13    Any medical or health care provider shall immediately
14recommend, to any pregnant individual woman who is being
15provided prenatal services and is suspected of having a
16substance use disorder as defined in the Substance Use
17Disorder Act, referral to a local substance use disorder
18treatment program licensed by the Department of Human Services
19or to a licensed hospital which provides substance abuse
20treatment services. The Department of Healthcare and Family
21Services shall assure coverage for the cost of treatment of
22the drug abuse or addiction for pregnant recipients in
23accordance with the Illinois Medicaid Program in conjunction
24with the Department of Human Services.
25    All medical providers providing medical assistance to
26pregnant individuals women under this Code shall receive

 

 

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

 

 

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

 

 

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

 

 

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1States Health Care Financing Administration to allow for the
2implementation of Partnerships under this Section.
3    The Illinois Department shall require health care
4providers to maintain records that document the medical care
5and services provided to recipients of Medical Assistance
6under this Article. Such records must be retained for a period
7of not less than 6 years from the date of service or as
8provided by applicable State law, whichever period is longer,
9except that if an audit is initiated within the required
10retention period then the records must be retained until the
11audit is completed and every exception is resolved. The
12Illinois Department shall require health care providers to
13make available, when authorized by the patient, in writing,
14the medical records in a timely fashion to other health care
15providers who are treating or serving persons eligible for
16Medical Assistance under this Article. All dispensers of
17medical services shall be required to maintain and retain
18business and professional records sufficient to fully and
19accurately document the nature, scope, details and receipt of
20the health care provided to persons eligible for medical
21assistance under this Code, in accordance with regulations
22promulgated by the Illinois Department. The rules and
23regulations shall require that proof of the receipt of
24prescription drugs, dentures, prosthetic devices and
25eyeglasses by eligible persons under this Section accompany
26each claim for reimbursement submitted by the dispenser of

 

 

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1such medical services. No such claims for reimbursement shall
2be approved for payment by the Illinois Department without
3such proof of receipt, unless the Illinois Department shall
4have put into effect and shall be operating a system of
5post-payment audit and review which shall, on a sampling
6basis, be deemed adequate by the Illinois Department to assure
7that such drugs, dentures, prosthetic devices and eyeglasses
8for which payment is being made are actually being received by
9eligible recipients. Within 90 days after September 16, 1984
10(the effective date of Public Act 83-1439), the Illinois
11Department shall establish a current list of acquisition costs
12for all prosthetic devices and any other items recognized as
13medical equipment and supplies reimbursable under this Article
14and shall update such list on a quarterly basis, except that
15the acquisition costs of all prescription drugs shall be
16updated no less frequently than every 30 days as required by
17Section 5-5.12.
18    Notwithstanding any other law to the contrary, the
19Illinois Department shall, within 365 days after July 22, 2013
20(the effective date of Public Act 98-104), establish
21procedures to permit skilled care facilities licensed under
22the Nursing Home Care Act to submit monthly billing claims for
23reimbursement purposes. Following development of these
24procedures, the Department shall, by July 1, 2016, test the
25viability of the new system and implement any necessary
26operational or structural changes to its information

 

 

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1technology platforms in order to allow for the direct
2acceptance and payment of nursing home claims.
3    Notwithstanding any other law to the contrary, the
4Illinois Department shall, within 365 days after August 15,
52014 (the effective date of Public Act 98-963), establish
6procedures to permit ID/DD facilities licensed under the ID/DD
7Community Care Act and MC/DD facilities licensed under the
8MC/DD Act to submit monthly billing claims for reimbursement
9purposes. Following development of these procedures, the
10Department shall have an additional 365 days to test the
11viability of the new system and to ensure that any necessary
12operational or structural changes to its information
13technology platforms are implemented.
14    The Illinois Department shall require all dispensers of
15medical services, other than an individual practitioner or
16group of practitioners, desiring to participate in the Medical
17Assistance program established under this Article to disclose
18all financial, beneficial, ownership, equity, surety or other
19interests in any and all firms, corporations, partnerships,
20associations, business enterprises, joint ventures, agencies,
21institutions or other legal entities providing any form of
22health care services in this State under this Article.
23    The Illinois Department may require that all dispensers of
24medical services desiring to participate in the medical
25assistance program established under this Article disclose,
26under such terms and conditions as the Illinois Department may

 

 

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

 

 

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

 

 

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1    which result in an inability to receive, process, or
2    adjudicate a claim, the 180-day period shall not begin
3    until the provider has been notified of the error.
4        (3) In the case of a provider for whom the Illinois
5    Department initiates the monthly billing process.
6        (4) In the case of a provider operated by a unit of
7    local government with a population exceeding 3,000,000
8    when local government funds finance federal participation
9    for claims payments.
10    For claims for services rendered during a period for which
11a recipient received retroactive eligibility, claims must be
12filed within 180 days after the Department determines the
13applicant is eligible. For claims for which the Illinois
14Department is not the primary payer, claims must be submitted
15to the Illinois Department within 180 days after the final
16adjudication by the primary payer.
17    In the case of long term care facilities, within 45
18calendar days of receipt by the facility of required
19prescreening information, new admissions with associated
20admission documents shall be submitted through the Medical
21Electronic Data Interchange (MEDI) or the Recipient
22Eligibility Verification (REV) System or shall be submitted
23directly to the Department of Human Services using required
24admission forms. Effective September 1, 2014, admission
25documents, including all prescreening information, must be
26submitted through MEDI or REV. Confirmation numbers assigned

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1recipient or enrollee is not already in receipt of same or
2similar equipment from another service provider, and that the
3refurbished durable medical equipment equally meets the needs
4of the recipient or enrollee. Nothing in this paragraph shall
5be construed to limit recipient or enrollee choice to obtain
6new durable medical equipment or place any additional prior
7authorization conditions on enrollees of managed care
8organizations.
9    The Department shall execute, relative to the nursing home
10prescreening project, written inter-agency agreements with the
11Department of Human Services and the Department on Aging, to
12effect the following: (i) intake procedures and common
13eligibility criteria for those persons who are receiving
14non-institutional services; and (ii) the establishment and
15development of non-institutional services in areas of the
16State where they are not currently available or are
17undeveloped; and (iii) notwithstanding any other provision of
18law, subject to federal approval, on and after July 1, 2012, an
19increase in the determination of need (DON) scores from 29 to
2037 for applicants for institutional and home and
21community-based long term care; if and only if federal
22approval is not granted, the Department may, in conjunction
23with other affected agencies, implement utilization controls
24or changes in benefit packages to effectuate a similar savings
25amount for this population; and (iv) no later than July 1,
262013, minimum level of care eligibility criteria for

 

 

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1institutional and home and community-based long term care; and
2(v) no later than October 1, 2013, establish procedures to
3permit long term care providers access to eligibility scores
4for individuals with an admission date who are seeking or
5receiving services from the long term care provider. In order
6to select the minimum level of care eligibility criteria, the
7Governor shall establish a workgroup that includes affected
8agency representatives and stakeholders representing the
9institutional and home and community-based long term care
10interests. This Section shall not restrict the Department from
11implementing lower level of care eligibility criteria for
12community-based services in circumstances where federal
13approval has been granted.
14    The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation
18and programs for monitoring of utilization of health care
19services and facilities, as it affects persons eligible for
20medical assistance under this Code.
21    The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24        (a) actual statistics and trends in utilization of
25    medical services by public aid recipients;
26        (b) actual statistics and trends in the provision of

 

 

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

 

 

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

 

 

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1lifetime restriction limit mandate.
2    On or after July 1, 2015, opioid antagonists prescribed
3for the treatment of an opioid overdose, including the
4medication product, administration devices, and any pharmacy
5fees related to the dispensing and administration of the
6opioid antagonist, shall be covered under the medical
7assistance program for persons who are otherwise eligible for
8medical assistance under this Article. As used in this
9Section, "opioid antagonist" means a drug that binds to opioid
10receptors and blocks or inhibits the effect of opioids acting
11on those receptors, including, but not limited to, naloxone
12hydrochloride or any other similarly acting drug approved by
13the U.S. Food and Drug Administration.
14    Upon federal approval, the Department shall provide
15coverage and reimbursement for all drugs that are approved for
16marketing by the federal Food and Drug Administration and that
17are recommended by the federal Public Health Service or the
18United States Centers for Disease Control and Prevention for
19pre-exposure prophylaxis and related pre-exposure prophylaxis
20services, including, but not limited to, HIV and sexually
21transmitted infection screening, treatment for sexually
22transmitted infections, medical monitoring, assorted labs, and
23counseling to reduce the likelihood of HIV infection among
24individuals who are not infected with HIV but who are at high
25risk of HIV infection.
26    A federally qualified health center, as defined in Section

 

 

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11905(l)(2)(B) of the federal Social Security Act, shall be
2reimbursed by the Department in accordance with the federally
3qualified health center's encounter rate for services provided
4to medical assistance recipients that are performed by a
5dental hygienist, as defined under the Illinois Dental
6Practice Act, working under the general supervision of a
7dentist and employed by a federally qualified health center.
8    Within 90 days after the effective date of this amendatory
9Act of the 102nd General Assembly, the Department shall seek
10federal approval of a State Plan amendment to expand coverage
11for family planning services that includes presumptive
12eligibility to individuals whose income is at or below 213% of
13the federal poverty level.
14(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
15100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
166-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
17eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
18100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
191-1-20; revised 9-18-19.)
 
20    (305 ILCS 5/5-5.24)
21    Sec. 5-5.24. Prenatal and perinatal care. The Department
22of Healthcare and Family Services may provide reimbursement
23under this Article for all prenatal and perinatal health care
24services that are provided for the purpose of preventing
25low-birthweight infants, reducing the need for neonatal

 

 

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1intensive care hospital services, and promoting perinatal and
2maternal health. These services may include comprehensive risk
3assessments for pregnant individuals women, individuals women
4with infants, and infants, lactation counseling, nutrition
5counseling, childbirth support, psychosocial counseling,
6treatment and prevention of periodontal disease, language
7translation, nurse home visitation, and other support services
8that have been proven to improve birth and maternal health
9outcomes. The Department shall maximize the use of preventive
10prenatal and perinatal health care services consistent with
11federal statutes, rules, and regulations. The Department of
12Public Aid (now Department of Healthcare and Family Services)
13shall develop a plan for prenatal and perinatal preventive
14health care and shall present the plan to the General Assembly
15by January 1, 2004. On or before January 1, 2006 and every 2
16years thereafter, the Department shall report to the General
17Assembly concerning the effectiveness of prenatal and
18perinatal health care services reimbursed under this Section
19in preventing low-birthweight infants and reducing the need
20for neonatal intensive care hospital services. Each such
21report shall include an evaluation of how the ratio of
22expenditures for treating low-birthweight infants compared
23with the investment in promoting healthy births and infants in
24local community areas throughout Illinois relates to healthy
25infant development in those areas.
26    On and after July 1, 2012, the Department shall reduce any

 

 

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1rate of reimbursement for services or other payments or alter
2any methodologies authorized by this Code to reduce any rate
3of reimbursement for services or other payments in accordance
4with Section 5-5e.
5(Source: P.A. 97-689, eff. 6-14-12.)
 
6    (305 ILCS 5/5-18.10 new)
7    Sec. 5-18.10. Reimbursement for postpartum visits.
8    (a) In this Section:
9    "Certified nurse midwife" means a person who exceeds the
10competencies for a midwife contained in the Essential
11Competencies for Midwifery Practice, published by the
12International Confederation of Midwives, and who qualifies as
13an advanced practice registered nurse.
14    "Community health worker" means a frontline public health
15worker who is a trusted member or has an unusually close
16understanding of the community served. This trusting
17relationship enables the community health worker to serve as a
18liaison, link, and intermediary between health and social
19services and the community to facilitate access to services
20and improve the quality and cultural competence of service
21delivery.
22    "International board-certified lactation consultant"
23means a health care professional who is certified by the
24International Board of Lactation Consultant Examiners and
25specializes in the clinical management of breastfeeding.

 

 

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1    "Lactation counselor" means a health care professional in
2lactation counseling who has demonstrated the necessary
3skills, knowledge, and attitudes to provide clinical
4breastfeeding counseling and management support to families
5who are thinking about breastfeeding or who have questions or
6problems during the course of breastfeeding.
7    "Peer navigator" means a health care professional who
8works with patients to overcome barriers related to medical
9care and to understand the health care system.
10    "Perinatal doula" means a trained provider of regular and
11voluntary physical, emotional, and educational support, but
12not medical or midwife care, to pregnant and birthing persons
13before, during, and after childbirth, otherwise known as the
14perinatal period.
15    "Public health nurse" means a registered nurse who
16promotes and protects the health of populations using
17knowledge from nursing, social, and public health sciences.
18    (b) Notwithstanding any other provision of this Article,
19the Illinois Department shall allow Medicaid providers to
20receive Medicaid reimbursement for a postpartum visit that is
21separate from Medicaid reimbursement for prenatal care and
22labor and delivery services.
23    (c) The medical assistance program shall cover a universal
24postpartum visit within the first 3 weeks after childbirth and
25a comprehensive visit within 4 to 12 weeks postpartum for
26persons who are otherwise eligible for medical assistance

 

 

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1under this Article. In addition, postpartum care services
2rendered by perinatal doulas, lactation counselors,
3international board-certified lactation consultants, public
4health nurses, certified nurse midwives, community health
5workers, and peer navigators shall be covered under the
6medical assistance program.
 
7    (305 ILCS 5/5-18.15 new)
8    Sec. 5-18.15. Perinatal doula and evidence-based home
9visiting services.
10    (a) In this Section:
11    "Home visiting" means a voluntary, evidence-based strategy
12used to support pregnant people, infants, and young children
13and their caregivers to promote infant, child, and maternal
14health, to foster educational development and school
15readiness, and to help prevent child abuse and neglect. Home
16visitors are trained professionals whose visits and activities
17focus on promoting strong parent-child attachment to foster
18healthy child development.
19    "Perinatal doula" means a trained provider of regular and
20voluntary physical, emotional, and educational support, but
21not medical or midwife care, to pregnant and birthing persons
22before, during, and after childbirth, otherwise known as the
23perinatal period.
24    "Perinatal doula training" means any doula training that
25focuses on providing support throughout the prenatal, labor

 

 

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1and delivery, or postpartum period, and reflects the type of
2doula care that the doula seeks to provide.
3    (b) Notwithstanding any other provision of this Article,
4perinatal doula services and evidence-based home visiting
5services shall be covered under the medical assistance program
6for persons who are otherwise eligible for medical assistance
7under this Article. Perinatal doula services include regular
8visits beginning in the prenatal period and continuing into
9the postnatal period, inclusive of continuous support during
10labor and delivery, that support healthy pregnancies and
11positive birth outcomes. Perinatal doula services may be
12embedded in an existing program, such as evidence-based home
13visiting. Perinatal doula services provided during the
14prenatal period may be provided weekly, services provided
15during the labor and delivery period may be provided for the
16entire duration of labor and the time immediately following
17birth, and services provided during the postpartum period may
18be provided up to 12 months postpartum.
19    (c) The Department of Healthcare and Family Services shall
20adopt rules to administer this Section. In this rulemaking,
21the Department shall consider the expertise of and consult
22with doula program experts, doula training providers,
23practicing doulas, and home visiting experts, along with State
24agencies implementing perinatal doula services and relevant
25bodies under the Illinois Early Learning Council. This body of
26experts shall inform the Department on the credentials

 

 

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1necessary for perinatal doula and home visiting services to be
2eligible for Medicaid reimbursement and the rate of
3reimbursement for home visiting and perinatal doula services
4in the prenatal, labor and delivery, and postpartum periods.
5Every 2 years, the Department shall assess the rates of
6reimbursement for perinatal doula and home visiting services
7and adjust rates accordingly.
8    (d) The Department shall seek such State Plan amendments
9or waivers as may be necessary to implement this Section and
10shall secure federal financial participation for expenditures
11made by the Department in accordance with this Section.
 
12    Section 99. Effective date. This Act takes effect upon
13becoming law.".