Illinois General Assembly - Full Text of HB0783
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Full Text of HB0783  102nd General Assembly

HB0783 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB0783

 

Introduced 2/10/2021, by Rep. Patrick Windhorst

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6  from Ch. 127, par. 526
5 ILCS 375/6.1  from Ch. 127, par. 526.1
305 ILCS 5/5-5  from Ch. 23, par. 5-5
305 ILCS 5/5-8  from Ch. 23, par. 5-8
305 ILCS 5/5-9  from Ch. 23, par. 5-9
305 ILCS 5/6-1  from Ch. 23, par. 6-1
410 ILCS 230/4-100  from Ch. 111 1/2, par. 4604-100

    Amends the State Employees Group Insurance Act of 1971, the Illinois Public Aid Code, and the Problem Pregnancy Health Services and Care Act. Restores the provisions that were amended by Public Act 100-538 to the form in which they existed before their amendment by Public Act 100-538.


LRB102 04196 LNS 14213 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB0783LRB102 04196 LNS 14213 b

1    AN ACT concerning abortion.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
 
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit the
18non-contributory portion of any such program to include the
19expenses of obtaining an abortion, induced miscarriage or
20induced premature birth unless, in the opinion of a physician,
21such procedures are necessary for the preservation of the life
22of the woman seeking such treatment, or except an induced
23premature birth intended to produce a live viable child and

 

 

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1such procedure is necessary for the health of the mother or the
2unborn child. The program may also include coverage for those
3who rely on treatment by prayer or spiritual means alone for
4healing in accordance with the tenets and practice of a
5recognized religious denomination.
6    The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits
11and as optional benefits, the medical services of
12practitioners in all categories licensed under the Medical
13Practice Act of 1987, (3) to include reasonable controls,
14which may include deductible and co-insurance provisions,
15applicable to some or all of the benefits, or a coordination of
16benefits provision, to prevent or minimize unnecessary
17utilization of the various hospital, surgical and medical
18expenses to be provided and to provide reasonable assurance of
19stability of the program, and (4) to provide benefits to the
20extent possible to members throughout the State, wherever
21located, on an equitable basis. Notwithstanding any other
22provision of this Section or Act, for all members or
23dependents who are eligible for benefits under Social Security
24or the Railroad Retirement system or who had sufficient
25Medicare-covered government employment, the Department shall
26reduce benefits which would otherwise be paid by Medicare, by

 

 

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1the amount of benefits for which the member or dependents are
2eligible under Medicare, except that such reduction in
3benefits shall apply only to those members or dependents who
4(1) first become eligible for such medicare coverage on or
5after the effective date of this amendatory Act of 1992; or (2)
6are Medicare-eligible members or dependents of a local
7government unit which began participation in the program on or
8after July 1, 1992; or (3) remain eligible for but no longer
9receive Medicare coverage which they had been receiving on or
10after the effective date of this amendatory Act of 1992.
11    Notwithstanding any other provisions of this Act, where a
12covered member or dependents are eligible for benefits under
13the federal Medicare health insurance program (Title XVIII of
14the Social Security Act as added by Public Law 89-97, 89th
15Congress), benefits paid under the State of Illinois program
16or plan will be reduced by the amount of benefits paid by
17Medicare. For members or dependents who are eligible for
18benefits under Social Security or the Railroad Retirement
19system or who had sufficient Medicare-covered government
20employment, benefits shall be reduced by the amount for which
21the member or dependent is eligible under Medicare, except
22that such reduction in benefits shall apply only to those
23members or dependents who (1) first become eligible for such
24Medicare coverage on or after the effective date of this
25amendatory Act of 1992; or (2) are Medicare-eligible members
26or dependents of a local government unit which began

 

 

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1participation in the program on or after July 1, 1992; or (3)
2remain eligible for, but no longer receive Medicare coverage
3which they had been receiving on or after the effective date of
4this amendatory Act of 1992. Premiums may be adjusted, where
5applicable, to an amount deemed by the Director to be
6reasonably consistent with any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code,
11shall pay the premiums for coverage, not exceeding the amount
12paid by the State for the non-contributory coverage for other
13members, under the group health benefits program under this
14Act. The Director shall determine the premiums to be paid by a
15member under this subsection (b).
16(Source: P.A. 100-538, eff. 1-1-18.)
 
17    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
18    Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.

 

 

HB0783- 5 -LRB102 04196 LNS 14213 b

1    However, nothing in this Act shall be construed to permit
2the noncontributory portion of any such program to include the
3expenses of obtaining an abortion, induced miscarriage or
4induced premature birth unless, in the opinion of a physician,
5such procedures are necessary for the preservation of the life
6of the woman seeking such treatment, or except an induced
7premature birth intended to produce a live viable child and
8such procedure is necessary for the health of the mother or her
9unborn child.
10(Source: P.A. 100-538, eff. 1-1-18.)
 
11    Section 10. The Illinois Public Aid Code is amended by
12changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
 
13    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
14    Sec. 5-5. Medical services. The Illinois Department, by
15rule, shall determine the quantity and quality of and the rate
16of reimbursement for the medical assistance for which payment
17will be authorized, and the medical services to be provided,
18which may include all or part of the following: (1) inpatient
19hospital services; (2) outpatient hospital services; (3) other
20laboratory and X-ray services; (4) skilled nursing home
21services; (5) physicians' services whether furnished in the
22office, the patient's home, a hospital, a skilled nursing
23home, or elsewhere; (6) medical care, or any other type of
24remedial care furnished by licensed practitioners; (7) home

 

 

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1health care services; (8) private duty nursing service; (9)
2clinic services; (10) dental services, including prevention
3and treatment of periodontal disease and dental caries disease
4for pregnant women, provided by an individual licensed to
5practice dentistry or dental surgery; for purposes of this
6item (10), "dental services" means diagnostic, preventive, or
7corrective procedures provided by or under the supervision of
8a dentist in the practice of his or her profession; (11)
9physical therapy and related services; (12) prescribed drugs,
10dentures, and prosthetic devices; and eyeglasses prescribed by
11a physician skilled in the diseases of the eye, or by an
12optometrist, whichever the person may select; (13) other
13diagnostic, screening, preventive, and rehabilitative
14services, including to ensure that the individual's need for
15intervention or treatment of mental disorders or substance use
16disorders or co-occurring mental health and substance use
17disorders is determined using a uniform screening, assessment,
18and evaluation process inclusive of criteria, for children and
19adults; for purposes of this item (13), a uniform screening,
20assessment, and evaluation process refers to a process that
21includes an appropriate evaluation and, as warranted, a
22referral; "uniform" does not mean the use of a singular
23instrument, tool, or process that all must utilize; (14)
24transportation and such other expenses as may be necessary;
25(15) medical treatment of sexual assault survivors, as defined
26in Section 1a of the Sexual Assault Survivors Emergency

 

 

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1Treatment Act, for injuries sustained as a result of the
2sexual assault, including examinations and laboratory tests to
3discover evidence which may be used in criminal proceedings
4arising from the sexual assault; (16) the diagnosis and
5treatment of sickle cell anemia; and (17) any other medical
6care, and any other type of remedial care recognized under the
7laws of this State, but not including abortions, or induced
8miscarriages or premature births, unless, in the opinion of a
9physician, such procedures are necessary for the preservation
10of the life of the woman seeking such treatment, or except an
11induced premature birth intended to produce a live viable
12child and such procedure is necessary for the health of the
13mother or her unborn child. The Illinois Department, by rule,
14shall prohibit any physician from providing medical assistance
15to anyone eligible therefor under this Code where such
16physician has been found guilty of performing an abortion
17procedure in a willful and wanton manner upon a woman who was
18not pregnant at the time such abortion procedure was
19performed. The term "any other type of remedial care" shall
20include nursing care and nursing home service for persons who
21rely on treatment by spiritual means alone through prayer for
22healing.
23    Notwithstanding any other provision of this Section, a
24comprehensive tobacco use cessation program that includes
25purchasing prescription drugs or prescription medical devices
26approved by the Food and Drug Administration shall be covered

 

 

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

 

 

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1for services provided by CPS's vendor or vendors to recipients
2of benefits in the medical assistance program under this Code,
3the Children's Health Insurance Program, or the Covering ALL
4KIDS Health Insurance Program shall be submitted to the
5Department or the MCE in which the individual is enrolled for
6payment and shall be reimbursed at the Department's or the
7MCE's established rates or rate methodologies for eyeglasses.
8    On and after July 1, 2012, the Department of Healthcare
9and Family Services may provide the following services to
10persons eligible for assistance under this Article who are
11participating in education, training or employment programs
12operated by the Department of Human Services as successor to
13the Department of Public Aid:
14        (1) dental services provided by or under the
15    supervision of a dentist; and
16        (2) eyeglasses prescribed by a physician skilled in
17    the diseases of the eye, or by an optometrist, whichever
18    the person may select.
19    On and after July 1, 2018, the Department of Healthcare
20and Family Services shall provide dental services to any adult
21who is otherwise eligible for assistance under the medical
22assistance program. As used in this paragraph, "dental
23services" means diagnostic, preventative, restorative, or
24corrective procedures, including procedures and services for
25the prevention and treatment of periodontal disease and dental
26caries disease, provided by an individual who is licensed to

 

 

HB0783- 10 -LRB102 04196 LNS 14213 b

1practice dentistry or dental surgery or who is under the
2supervision of a dentist in the practice of his or her
3profession.
4    On and after July 1, 2018, targeted dental services, as
5set forth in Exhibit D of the Consent Decree entered by the
6United States District Court for the Northern District of
7Illinois, Eastern Division, in the matter of Memisovski v.
8Maram, Case No. 92 C 1982, that are provided to adults under
9the medical assistance program shall be established at no less
10than the rates set forth in the "New Rate" column in Exhibit D
11of the Consent Decree for targeted dental services that are
12provided to persons under the age of 18 under the medical
13assistance program.
14    Notwithstanding any other provision of this Code and
15subject to federal approval, the Department may adopt rules to
16allow a dentist who is volunteering his or her service at no
17cost to render dental services through an enrolled
18not-for-profit health clinic without the dentist personally
19enrolling as a participating provider in the medical
20assistance program. A not-for-profit health clinic shall
21include a public health clinic or Federally Qualified Health
22Center or other enrolled provider, as determined by the
23Department, through which dental services covered under this
24Section are performed. The Department shall establish a
25process for payment of claims for reimbursement for covered
26dental services rendered under this provision.

 

 

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1    The Illinois Department, by rule, may distinguish and
2classify the medical services to be provided only in
3accordance with the classes of persons designated in Section
45-2.
5    The Department of Healthcare and Family Services must
6provide coverage and reimbursement for amino acid-based
7elemental formulas, regardless of delivery method, for the
8diagnosis and treatment of (i) eosinophilic disorders and (ii)
9short bowel syndrome when the prescribing physician has issued
10a written order stating that the amino acid-based elemental
11formula is medically necessary.
12    The Illinois Department shall authorize the provision of,
13and shall authorize payment for, screening by low-dose
14mammography for the presence of occult breast cancer for women
1535 years of age or older who are eligible for medical
16assistance under this Article, as follows:
17        (A) A baseline mammogram for women 35 to 39 years of
18    age.
19        (B) An annual mammogram for women 40 years of age or
20    older.
21        (C) A mammogram at the age and intervals considered
22    medically necessary by the woman's health care provider
23    for women under 40 years of age and having a family history
24    of breast cancer, prior personal history of breast cancer,
25    positive genetic testing, or other risk factors.
26        (D) A comprehensive ultrasound screening and MRI of an

 

 

HB0783- 12 -LRB102 04196 LNS 14213 b

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

 

 

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1    "Diagnostic mammography" means a method of screening that
2is designed to evaluate an abnormality in a breast, including
3an abnormality seen or suspected on a screening mammogram or a
4subjective or objective abnormality otherwise detected in the
5breast.
6    "Low-dose mammography" means the x-ray examination of the
7breast using equipment dedicated specifically for mammography,
8including the x-ray tube, filter, compression device, and
9image receptor, with an average radiation exposure delivery of
10less than one rad per breast for 2 views of an average size
11breast. The term also includes digital mammography and
12includes breast tomosynthesis.
13    "Breast tomosynthesis" means a radiologic procedure that
14involves the acquisition of projection images over the
15stationary breast to produce cross-sectional digital
16three-dimensional images of the breast.
17    If, at any time, the Secretary of the United States
18Department of Health and Human Services, or its successor
19agency, promulgates rules or regulations to be published in
20the Federal Register or publishes a comment in the Federal
21Register or issues an opinion, guidance, or other action that
22would require the State, pursuant to any provision of the
23Patient Protection and Affordable Care Act (Public Law
24111-148), including, but not limited to, 42 U.S.C.
2518031(d)(3)(B) or any successor provision, to defray the cost
26of any coverage for breast tomosynthesis outlined in this

 

 

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1paragraph, then the requirement that an insurer cover breast
2tomosynthesis is inoperative other than any such coverage
3authorized under Section 1902 of the Social Security Act, 42
4U.S.C. 1396a, and the State shall not assume any obligation
5for the cost of coverage for breast tomosynthesis set forth in
6this paragraph.
7    On and after January 1, 2016, the Department shall ensure
8that all networks of care for adult clients of the Department
9include access to at least one breast imaging Center of
10Imaging Excellence as certified by the American College of
11Radiology.
12    On and after January 1, 2012, providers participating in a
13quality improvement program approved by the Department shall
14be reimbursed for screening and diagnostic mammography at the
15same rate as the Medicare program's rates, including the
16increased reimbursement for digital mammography.
17    The Department shall convene an expert panel including
18representatives of hospitals, free-standing mammography
19facilities, and doctors, including radiologists, to establish
20quality standards for mammography.
21    On and after January 1, 2017, providers participating in a
22breast cancer treatment quality improvement program approved
23by the Department shall be reimbursed for breast cancer
24treatment at a rate that is no lower than 95% of the Medicare
25program's rates for the data elements included in the breast
26cancer treatment quality program.

 

 

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

 

 

HB0783- 16 -LRB102 04196 LNS 14213 b

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

 

 

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1prenatal services and is suspected of having a substance use
2disorder as defined in the Substance Use Disorder Act,
3referral to a local substance use disorder treatment program
4licensed by the Department of Human Services or to a licensed
5hospital which provides substance abuse treatment services.
6The Department of Healthcare and Family Services shall assure
7coverage for the cost of treatment of the drug abuse or
8addiction for pregnant recipients in accordance with the
9Illinois Medicaid Program in conjunction with the Department
10of Human Services.
11    All medical providers providing medical assistance to
12pregnant women under this Code shall receive information from
13the Department on the availability of services under any
14program providing case management services for addicted women,
15including information on appropriate referrals for other
16social services that may be needed by addicted women in
17addition to treatment for addiction.
18    The Illinois Department, in cooperation with the
19Departments of Human Services (as successor to the Department
20of Alcoholism and Substance Abuse) and Public Health, through
21a public awareness campaign, may provide information
22concerning treatment for alcoholism and drug abuse and
23addiction, prenatal health care, and other pertinent programs
24directed at reducing the number of drug-affected infants born
25to recipients of medical assistance.
26    Neither the Department of Healthcare and Family Services

 

 

HB0783- 18 -LRB102 04196 LNS 14213 b

1nor the Department of Human Services shall sanction the
2recipient solely on the basis of her substance abuse.
3    The Illinois Department shall establish such regulations
4governing the dispensing of health services under this Article
5as it shall deem appropriate. The Department should seek the
6advice of formal professional advisory committees appointed by
7the Director of the Illinois Department for the purpose of
8providing regular advice on policy and administrative matters,
9information dissemination and educational activities for
10medical and health care providers, and consistency in
11procedures to the Illinois Department.
12    The Illinois Department may develop and contract with
13Partnerships of medical providers to arrange medical services
14for persons eligible under Section 5-2 of this Code.
15Implementation of this Section may be by demonstration
16projects in certain geographic areas. The Partnership shall be
17represented by a sponsor organization. The Department, by
18rule, shall develop qualifications for sponsors of
19Partnerships. Nothing in this Section shall be construed to
20require that the sponsor organization be a medical
21organization.
22    The sponsor must negotiate formal written contracts with
23medical providers for physician services, inpatient and
24outpatient hospital care, home health services, treatment for
25alcoholism and substance abuse, and other services determined
26necessary by the Illinois Department by rule for delivery by

 

 

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1Partnerships. Physician services must include prenatal and
2obstetrical care. The Illinois Department shall reimburse
3medical services delivered by Partnership providers to clients
4in target areas according to provisions of this Article and
5the Illinois Health Finance Reform Act, except that:
6        (1) Physicians participating in a Partnership and
7    providing certain services, which shall be determined by
8    the Illinois Department, to persons in areas covered by
9    the Partnership may receive an additional surcharge for
10    such services.
11        (2) The Department may elect to consider and negotiate
12    financial incentives to encourage the development of
13    Partnerships and the efficient delivery of medical care.
14        (3) Persons receiving medical services through
15    Partnerships may receive medical and case management
16    services above the level usually offered through the
17    medical assistance program.
18    Medical providers shall be required to meet certain
19qualifications to participate in Partnerships to ensure the
20delivery of high quality medical services. These
21qualifications shall be determined by rule of the Illinois
22Department and may be higher than qualifications for
23participation in the medical assistance program. Partnership
24sponsors may prescribe reasonable additional qualifications
25for participation by medical providers, only with the prior
26written approval of the Illinois Department.

 

 

HB0783- 20 -LRB102 04196 LNS 14213 b

1    Nothing in this Section shall limit the free choice of
2practitioners, hospitals, and other providers of medical
3services by clients. In order to ensure patient freedom of
4choice, the Illinois Department shall immediately promulgate
5all rules and take all other necessary actions so that
6provided services may be accessed from therapeutically
7certified optometrists to the full extent of the Illinois
8Optometric Practice Act of 1987 without discriminating between
9service providers.
10    The Department shall apply for a waiver from the United
11States Health Care Financing Administration to allow for the
12implementation of Partnerships under this Section.
13    The Illinois Department shall require health care
14providers to maintain records that document the medical care
15and services provided to recipients of Medical Assistance
16under this Article. Such records must be retained for a period
17of not less than 6 years from the date of service or as
18provided by applicable State law, whichever period is longer,
19except that if an audit is initiated within the required
20retention period then the records must be retained until the
21audit is completed and every exception is resolved. The
22Illinois Department shall require health care providers to
23make available, when authorized by the patient, in writing,
24the medical records in a timely fashion to other health care
25providers who are treating or serving persons eligible for
26Medical Assistance under this Article. All dispensers of

 

 

HB0783- 21 -LRB102 04196 LNS 14213 b

1medical services shall be required to maintain and retain
2business and professional records sufficient to fully and
3accurately document the nature, scope, details and receipt of
4the health care provided to persons eligible for medical
5assistance under this Code, in accordance with regulations
6promulgated by the Illinois Department. The rules and
7regulations shall require that proof of the receipt of
8prescription drugs, dentures, prosthetic devices and
9eyeglasses by eligible persons under this Section accompany
10each claim for reimbursement submitted by the dispenser of
11such medical services. No such claims for reimbursement shall
12be approved for payment by the Illinois Department without
13such proof of receipt, unless the Illinois Department shall
14have put into effect and shall be operating a system of
15post-payment audit and review which shall, on a sampling
16basis, be deemed adequate by the Illinois Department to assure
17that such drugs, dentures, prosthetic devices and eyeglasses
18for which payment is being made are actually being received by
19eligible recipients. Within 90 days after September 16, 1984
20(the effective date of Public Act 83-1439), the Illinois
21Department shall establish a current list of acquisition costs
22for all prosthetic devices and any other items recognized as
23medical equipment and supplies reimbursable under this Article
24and shall update such list on a quarterly basis, except that
25the acquisition costs of all prescription drugs shall be
26updated no less frequently than every 30 days as required by

 

 

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1Section 5-5.12.
2    The rules and regulations of the Illinois Department shall
3require that a written statement including the required
4opinion of a physician shall accompany any claim for
5reimbursement for abortions, or induced miscarriages or
6premature births. This statement shall indicate what
7procedures were used in providing such medical services.
8    Notwithstanding any other law to the contrary, the
9Illinois Department shall, within 365 days after July 22, 2013
10(the effective date of Public Act 98-104), establish
11procedures to permit skilled care facilities licensed under
12the Nursing Home Care Act to submit monthly billing claims for
13reimbursement purposes. Following development of these
14procedures, the Department shall, by July 1, 2016, test the
15viability of the new system and implement any necessary
16operational or structural changes to its information
17technology platforms in order to allow for the direct
18acceptance and payment of nursing home claims.
19    Notwithstanding any other law to the contrary, the
20Illinois Department shall, within 365 days after August 15,
212014 (the effective date of Public Act 98-963), establish
22procedures to permit ID/DD facilities licensed under the ID/DD
23Community Care Act and MC/DD facilities licensed under the
24MC/DD Act to submit monthly billing claims for reimbursement
25purposes. Following development of these procedures, the
26Department shall have an additional 365 days to test the

 

 

HB0783- 23 -LRB102 04196 LNS 14213 b

1viability of the new system and to ensure that any necessary
2operational or structural changes to its information
3technology platforms are implemented.
4    The Illinois Department shall require all dispensers of
5medical services, other than an individual practitioner or
6group of practitioners, desiring to participate in the Medical
7Assistance program established under this Article to disclose
8all financial, beneficial, ownership, equity, surety or other
9interests in any and all firms, corporations, partnerships,
10associations, business enterprises, joint ventures, agencies,
11institutions or other legal entities providing any form of
12health care services in this State under this Article.
13    The Illinois Department may require that all dispensers of
14medical services desiring to participate in the medical
15assistance program established under this Article disclose,
16under such terms and conditions as the Illinois Department may
17by rule establish, all inquiries from clients and attorneys
18regarding medical bills paid by the Illinois Department, which
19inquiries could indicate potential existence of claims or
20liens for the Illinois Department.
21    Enrollment of a vendor shall be subject to a provisional
22period and shall be conditional for one year. During the
23period of conditional enrollment, the Department may terminate
24the vendor's eligibility to participate in, or may disenroll
25the vendor from, the medical assistance program without cause.
26Unless otherwise specified, such termination of eligibility or

 

 

HB0783- 24 -LRB102 04196 LNS 14213 b

1disenrollment is not subject to the Department's hearing
2process. However, a disenrolled vendor may reapply without
3penalty.
4    The Department has the discretion to limit the conditional
5enrollment period for vendors based upon category of risk of
6the vendor.
7    Prior to enrollment and during the conditional enrollment
8period in the medical assistance program, all vendors shall be
9subject to enhanced oversight, screening, and review based on
10the risk of fraud, waste, and abuse that is posed by the
11category of risk of the vendor. The Illinois Department shall
12establish the procedures for oversight, screening, and review,
13which may include, but need not be limited to: criminal and
14financial background checks; fingerprinting; license,
15certification, and authorization verifications; unscheduled or
16unannounced site visits; database checks; prepayment audit
17reviews; audits; payment caps; payment suspensions; and other
18screening as required by federal or State law.
19    The Department shall define or specify the following: (i)
20by provider notice, the "category of risk of the vendor" for
21each type of vendor, which shall take into account the level of
22screening applicable to a particular category of vendor under
23federal law and regulations; (ii) by rule or provider notice,
24the maximum length of the conditional enrollment period for
25each category of risk of the vendor; and (iii) by rule, the
26hearing rights, if any, afforded to a vendor in each category

 

 

HB0783- 25 -LRB102 04196 LNS 14213 b

1of risk of the vendor that is terminated or disenrolled during
2the conditional enrollment period.
3    To be eligible for payment consideration, a vendor's
4payment claim or bill, either as an initial claim or as a
5resubmitted claim following prior rejection, must be received
6by the Illinois Department, or its fiscal intermediary, no
7later than 180 days after the latest date on the claim on which
8medical goods or services were provided, with the following
9exceptions:
10        (1) In the case of a provider whose enrollment is in
11    process by the Illinois Department, the 180-day period
12    shall not begin until the date on the written notice from
13    the Illinois Department that the provider enrollment is
14    complete.
15        (2) In the case of errors attributable to the Illinois
16    Department or any of its claims processing intermediaries
17    which result in an inability to receive, process, or
18    adjudicate a claim, the 180-day period shall not begin
19    until the provider has been notified of the error.
20        (3) In the case of a provider for whom the Illinois
21    Department initiates the monthly billing process.
22        (4) In the case of a provider operated by a unit of
23    local government with a population exceeding 3,000,000
24    when local government funds finance federal participation
25    for claims payments.
26    For claims for services rendered during a period for which

 

 

HB0783- 26 -LRB102 04196 LNS 14213 b

1a recipient received retroactive eligibility, claims must be
2filed within 180 days after the Department determines the
3applicant is eligible. For claims for which the Illinois
4Department is not the primary payer, claims must be submitted
5to the Illinois Department within 180 days after the final
6adjudication by the primary payer.
7    In the case of long term care facilities, within 45
8calendar days of receipt by the facility of required
9prescreening information, new admissions with associated
10admission documents shall be submitted through the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or shall be submitted
13directly to the Department of Human Services using required
14admission forms. Effective September 1, 2014, admission
15documents, including all prescreening information, must be
16submitted through MEDI or REV. Confirmation numbers assigned
17to an accepted transaction shall be retained by a facility to
18verify timely submittal. Once an admission transaction has
19been completed, all resubmitted claims following prior
20rejection are subject to receipt no later than 180 days after
21the admission transaction has been completed.
22    Claims that are not submitted and received in compliance
23with the foregoing requirements shall not be eligible for
24payment under the medical assistance program, and the State
25shall have no liability for payment of those claims.
26    To the extent consistent with applicable information and

 

 

HB0783- 27 -LRB102 04196 LNS 14213 b

1privacy, security, and disclosure laws, State and federal
2agencies and departments shall provide the Illinois Department
3access to confidential and other information and data
4necessary to perform eligibility and payment verifications and
5other Illinois Department functions. This includes, but is not
6limited to: information pertaining to licensure;
7certification; earnings; immigration status; citizenship; wage
8reporting; unearned and earned income; pension income;
9employment; supplemental security income; social security
10numbers; National Provider Identifier (NPI) numbers; the
11National Practitioner Data Bank (NPDB); program and agency
12exclusions; taxpayer identification numbers; tax delinquency;
13corporate information; and death records.
14    The Illinois Department shall enter into agreements with
15State agencies and departments, and is authorized to enter
16into agreements with federal agencies and departments, under
17which such agencies and departments shall share data necessary
18for medical assistance program integrity functions and
19oversight. The Illinois Department shall develop, in
20cooperation with other State departments and agencies, and in
21compliance with applicable federal laws and regulations,
22appropriate and effective methods to share such data. At a
23minimum, and to the extent necessary to provide data sharing,
24the Illinois Department shall enter into agreements with State
25agencies and departments, and is authorized to enter into
26agreements with federal agencies and departments, including,

 

 

HB0783- 28 -LRB102 04196 LNS 14213 b

1but not limited to: the Secretary of State; the Department of
2Revenue; the Department of Public Health; the Department of
3Human Services; and the Department of Financial and
4Professional Regulation.
5    Beginning in fiscal year 2013, the Illinois Department
6shall set forth a request for information to identify the
7benefits of a pre-payment, post-adjudication, and post-edit
8claims system with the goals of streamlining claims processing
9and provider reimbursement, reducing the number of pending or
10rejected claims, and helping to ensure a more transparent
11adjudication process through the utilization of: (i) provider
12data verification and provider screening technology; and (ii)
13clinical code editing; and (iii) pre-pay, pre- or
14post-adjudicated predictive modeling with an integrated case
15management system with link analysis. Such a request for
16information shall not be considered as a request for proposal
17or as an obligation on the part of the Illinois Department to
18take any action or acquire any products or services.
19    The Illinois Department shall establish policies,
20procedures, standards and criteria by rule for the
21acquisition, repair and replacement of orthotic and prosthetic
22devices and durable medical equipment. Such rules shall
23provide, but not be limited to, the following services: (1)
24immediate repair or replacement of such devices by recipients;
25and (2) rental, lease, purchase or lease-purchase of durable
26medical equipment in a cost-effective manner, taking into

 

 

HB0783- 29 -LRB102 04196 LNS 14213 b

1consideration the recipient's medical prognosis, the extent of
2the recipient's needs, and the requirements and costs for
3maintaining such equipment. Subject to prior approval, such
4rules shall enable a recipient to temporarily acquire and use
5alternative or substitute devices or equipment pending repairs
6or replacements of any device or equipment previously
7authorized for such recipient by the Department.
8Notwithstanding any provision of Section 5-5f to the contrary,
9the Department may, by rule, exempt certain replacement
10wheelchair parts from prior approval and, for wheelchairs,
11wheelchair parts, wheelchair accessories, and related seating
12and positioning items, determine the wholesale price by
13methods other than actual acquisition costs.
14    The Department shall require, by rule, all providers of
15durable medical equipment to be accredited by an accreditation
16organization approved by the federal Centers for Medicare and
17Medicaid Services and recognized by the Department in order to
18bill the Department for providing durable medical equipment to
19recipients. No later than 15 months after the effective date
20of the rule adopted pursuant to this paragraph, all providers
21must meet the accreditation requirement.
22    In order to promote environmental responsibility, meet the
23needs of recipients and enrollees, and achieve significant
24cost savings, the Department, or a managed care organization
25under contract with the Department, may provide recipients or
26managed care enrollees who have a prescription or Certificate

 

 

HB0783- 30 -LRB102 04196 LNS 14213 b

1of Medical Necessity access to refurbished durable medical
2equipment under this Section (excluding prosthetic and
3orthotic devices as defined in the Orthotics, Prosthetics, and
4Pedorthics Practice Act and complex rehabilitation technology
5products and associated services) through the State's
6assistive technology program's reutilization program, using
7staff with the Assistive Technology Professional (ATP)
8Certification if the refurbished durable medical equipment:
9(i) is available; (ii) is less expensive, including shipping
10costs, than new durable medical equipment of the same type;
11(iii) is able to withstand at least 3 years of use; (iv) is
12cleaned, disinfected, sterilized, and safe in accordance with
13federal Food and Drug Administration regulations and guidance
14governing the reprocessing of medical devices in health care
15settings; and (v) equally meets the needs of the recipient or
16enrollee. The reutilization program shall confirm that the
17recipient or enrollee is not already in receipt of same or
18similar equipment from another service provider, and that the
19refurbished durable medical equipment equally meets the needs
20of the recipient or enrollee. Nothing in this paragraph shall
21be construed to limit recipient or enrollee choice to obtain
22new durable medical equipment or place any additional prior
23authorization conditions on enrollees of managed care
24organizations.
25    The Department shall execute, relative to the nursing home
26prescreening project, written inter-agency agreements with the

 

 

HB0783- 31 -LRB102 04196 LNS 14213 b

1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the
6State where they are not currently available or are
7undeveloped; and (iii) notwithstanding any other provision of
8law, subject to federal approval, on and after July 1, 2012, an
9increase in the determination of need (DON) scores from 29 to
1037 for applicants for institutional and home and
11community-based long term care; if and only if federal
12approval is not granted, the Department may, in conjunction
13with other affected agencies, implement utilization controls
14or changes in benefit packages to effectuate a similar savings
15amount for this population; and (iv) no later than July 1,
162013, minimum level of care eligibility criteria for
17institutional and home and community-based long term care; and
18(v) no later than October 1, 2013, establish procedures to
19permit long term care providers access to eligibility scores
20for individuals with an admission date who are seeking or
21receiving services from the long term care provider. In order
22to select the minimum level of care eligibility criteria, the
23Governor shall establish a workgroup that includes affected
24agency representatives and stakeholders representing the
25institutional and home and community-based long term care
26interests. This Section shall not restrict the Department from

 

 

HB0783- 32 -LRB102 04196 LNS 14213 b

1implementing lower level of care eligibility criteria for
2community-based services in circumstances where federal
3approval has been granted.
4    The Illinois Department shall develop and operate, in
5cooperation with other State Departments and agencies and in
6compliance with applicable federal laws and regulations,
7appropriate and effective systems of health care evaluation
8and programs for monitoring of utilization of health care
9services and facilities, as it affects persons eligible for
10medical assistance under this Code.
11    The Illinois Department shall report annually to the
12General Assembly, no later than the second Friday in April of
131979 and each year thereafter, in regard to:
14        (a) actual statistics and trends in utilization of
15    medical services by public aid recipients;
16        (b) actual statistics and trends in the provision of
17    the various medical services by medical vendors;
18        (c) current rate structures and proposed changes in
19    those rate structures for the various medical vendors; and
20        (d) efforts at utilization review and control by the
21    Illinois Department.
22    The period covered by each report shall be the 3 years
23ending on the June 30 prior to the report. The report shall
24include suggested legislation for consideration by the General
25Assembly. The requirement for reporting to the General
26Assembly shall be satisfied by filing copies of the report as

 

 

HB0783- 33 -LRB102 04196 LNS 14213 b

1required by Section 3.1 of the General Assembly Organization
2Act, and filing such additional copies with the State
3Government Report Distribution Center for the General Assembly
4as is required under paragraph (t) of Section 7 of the State
5Library Act.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12    On and after July 1, 2012, the Department shall reduce any
13rate of reimbursement for services or other payments or alter
14any methodologies authorized by this Code to reduce any rate
15of reimbursement for services or other payments in accordance
16with Section 5-5e.
17    Because kidney transplantation can be an appropriate,
18cost-effective alternative to renal dialysis when medically
19necessary and notwithstanding the provisions of Section 1-11
20of this Code, beginning October 1, 2014, the Department shall
21cover kidney transplantation for noncitizens with end-stage
22renal disease who are not eligible for comprehensive medical
23benefits, who meet the residency requirements of Section 5-3
24of this Code, and who would otherwise meet the financial
25requirements of the appropriate class of eligible persons
26under Section 5-2 of this Code. To qualify for coverage of

 

 

HB0783- 34 -LRB102 04196 LNS 14213 b

1kidney transplantation, such person must be receiving
2emergency renal dialysis services covered by the Department.
3Providers under this Section shall be prior approved and
4certified by the Department to perform kidney transplantation
5and the services under this Section shall be limited to
6services associated with kidney transplantation.
7    Notwithstanding any other provision of this Code to the
8contrary, on or after July 1, 2015, all FDA approved forms of
9medication assisted treatment prescribed for the treatment of
10alcohol dependence or treatment of opioid dependence shall be
11covered under both fee for service and managed care medical
12assistance programs for persons who are otherwise eligible for
13medical assistance under this Article and shall not be subject
14to any (1) utilization control, other than those established
15under the American Society of Addiction Medicine patient
16placement criteria, (2) prior authorization mandate, or (3)
17lifetime restriction limit mandate.
18    On or after July 1, 2015, opioid antagonists prescribed
19for the treatment of an opioid overdose, including the
20medication product, administration devices, and any pharmacy
21fees related to the dispensing and administration of the
22opioid antagonist, shall be covered under the medical
23assistance program for persons who are otherwise eligible for
24medical assistance under this Article. As used in this
25Section, "opioid antagonist" means a drug that binds to opioid
26receptors and blocks or inhibits the effect of opioids acting

 

 

HB0783- 35 -LRB102 04196 LNS 14213 b

1on those receptors, including, but not limited to, naloxone
2hydrochloride or any other similarly acting drug approved by
3the U.S. Food and Drug Administration.
4    Upon federal approval, the Department shall provide
5coverage and reimbursement for all drugs that are approved for
6marketing by the federal Food and Drug Administration and that
7are recommended by the federal Public Health Service or the
8United States Centers for Disease Control and Prevention for
9pre-exposure prophylaxis and related pre-exposure prophylaxis
10services, including, but not limited to, HIV and sexually
11transmitted infection screening, treatment for sexually
12transmitted infections, medical monitoring, assorted labs, and
13counseling to reduce the likelihood of HIV infection among
14individuals who are not infected with HIV but who are at high
15risk of HIV infection.
16    A federally qualified health center, as defined in Section
171905(l)(2)(B) of the federal Social Security Act, shall be
18reimbursed by the Department in accordance with the federally
19qualified health center's encounter rate for services provided
20to medical assistance recipients that are performed by a
21dental hygienist, as defined under the Illinois Dental
22Practice Act, working under the general supervision of a
23dentist and employed by a federally qualified health center.
24(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
25100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
266-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,

 

 

HB0783- 36 -LRB102 04196 LNS 14213 b

1eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
2100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
31-1-20; revised 9-18-19.)
 
4    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
5    Sec. 5-8. Practitioners. In supplying medical assistance,
6the Illinois Department may provide for the legally authorized
7services of (i) persons licensed under the Medical Practice
8Act of 1987, as amended, except as hereafter in this Section
9stated, whether under a general or limited license, (ii)
10persons licensed under the Nurse Practice Act as advanced
11practice registered nurses, regardless of whether or not the
12persons have written collaborative agreements, (iii) persons
13licensed or registered under other laws of this State to
14provide dental, medical, pharmaceutical, optometric,
15podiatric, or nursing services, or other remedial care
16recognized under State law, (iv) persons licensed under other
17laws of this State as a clinical social worker, and (v) persons
18licensed under other laws of this State as physician
19assistants. The Department shall adopt rules, no later than 90
20days after January 1, 2017 (the effective date of Public Act
2199-621), for the legally authorized services of persons
22licensed under other laws of this State as a clinical social
23worker. The Department may not provide for legally authorized
24services of any physician who has been convicted of having
25performed an abortion procedure in a willful and wanton manner

 

 

HB0783- 37 -LRB102 04196 LNS 14213 b

1on a woman who was not pregnant at the time such abortion
2procedure was performed. The utilization of the services of
3persons engaged in the treatment or care of the sick, which
4persons are not required to be licensed or registered under
5the laws of this State, is not prohibited by this Section.
6(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
7100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff.
81-1-18; 100-863, eff. 8-14-18.)
 
9    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
10    Sec. 5-9. Choice of medical dispensers. Applicants and
11recipients shall be entitled to free choice of those qualified
12practitioners, hospitals, nursing homes, and other dispensers
13of medical services meeting the requirements and complying
14with the rules and regulations of the Illinois Department.
15However, the Director of Healthcare and Family Services may,
16after providing reasonable notice and opportunity for hearing,
17deny, suspend or terminate any otherwise qualified person,
18firm, corporation, association, agency, institution, or other
19legal entity, from participation as a vendor of goods or
20services under the medical assistance program authorized by
21this Article if the Director finds such vendor of medical
22services in violation of this Act or the policy or rules and
23regulations issued pursuant to this Act. Any physician who has
24been convicted of performing an abortion procedure in a
25willful and wanton manner upon a woman who was not pregnant at

 

 

HB0783- 38 -LRB102 04196 LNS 14213 b

1the time such abortion procedure was performed shall be
2automatically removed from the list of physicians qualified to
3participate as a vendor of medical services under the medical
4assistance program authorized by this Article.
5(Source: P.A. 100-538, eff. 1-1-18.)
 
6    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
7    Sec. 6-1. Eligibility requirements. Financial aid in
8meeting basic maintenance requirements shall be given under
9this Article to or in behalf of persons who meet the
10eligibility conditions of Sections 6-1.1 through 6-1.10. In
11addition, each unit of local government subject to this
12Article shall provide persons receiving financial aid in
13meeting basic maintenance requirements with financial aid for
14either (a) necessary treatment, care, and supplies required
15because of illness or disability, or (b) acute medical
16treatment, care, and supplies only. If a local governmental
17unit elects to provide financial aid for acute medical
18treatment, care, and supplies only, the general types of acute
19medical treatment, care, and supplies for which financial aid
20is provided shall be specified in the general assistance rules
21of the local governmental unit, which rules shall provide that
22financial aid is provided, at a minimum, for acute medical
23treatment, care, or supplies necessitated by a medical
24condition for which prior approval or authorization of medical
25treatment, care, or supplies is not required by the general

 

 

HB0783- 39 -LRB102 04196 LNS 14213 b

1assistance rules of the Illinois Department. Nothing in this
2Article shall be construed to permit the granting of financial
3aid where the purpose of such aid is to obtain an abortion,
4induced miscarriage or induced premature birth unless, in the
5opinion of a physician, such procedures are necessary for the
6preservation of the life of the woman seeking such treatment,
7or except an induced premature birth intended to produce a
8live viable child and such procedure is necessary for the
9health of the mother or her unborn child.
10(Source: P.A. 100-538, eff. 1-1-18.)
 
11    Section 15. The Problem Pregnancy Health Services and Care
12Act is amended by changing Section 4-100 as follows:
 
13    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
14    Sec. 4-100. The Department may make grants to nonprofit
15agencies and organizations which do not use such grants to
16refer or counsel for, or perform, abortions and which
17coordinate and establish linkages among services that will
18further the purposes of this Act and, where appropriate, will
19provide, supplement, or improve the quality of such services.
20(Source: P.A. 100-538, eff. 1-1-18.)