State of Illinois
2021 and 2022


Introduced 1/21/2022, by Rep. Deb Conroy


215 ILCS 5/356z.23
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Illinois Insurance Code. Prohibits an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in the State after the effective date of the amendatory Act that provides coverage for naloxone hydrochloride from imposing a copayment on the coverage provided. Amends the Medical Assistance Article of the Illinois Public Aid Code. Prohibits the Department of Healthcare and Family Services from imposing a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program.

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HB4408LRB102 22908 KTG 32061 b

1    AN ACT concerning health insurance co-pays.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.23 as follows:
6    (215 ILCS 5/356z.23)
7    Sec. 356z.23. Coverage for opioid antagonists.
8    (a) An individual or group policy of accident and health
9insurance amended, delivered, issued, or renewed in this State
10after the effective date of this amendatory Act of the 99th
11General Assembly that provides coverage for prescription drugs
12must provide coverage for at least one opioid antagonist,
13including the medication product, administration devices, and
14any pharmacy administration fees related to the dispensing of
15the opioid antagonist. This coverage must include refills for
16expired or utilized opioid antagonists.
17    (a-5) Notwithstanding subsection (a), no individual or
18group policy of accident and health insurance amended,
19delivered, issued, or renewed in this State after the
20effective date of this amendatory Act of the 102nd General
21Assembly that provides coverage for naloxone hydrochloride
22shall impose a copayment on the coverage provided.
23    (b) As used in this Section, "opioid antagonist" means a



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1drug that binds to opioid receptors and blocks or inhibits the
2effect of opioids acting on those receptors, including, but
3not limited to, naloxone hydrochloride or any other similarly
4acting drug approved by the U.S. Food and Drug Administration.
5(Source: P.A. 99-480, eff. 9-9-15.)
6    Section 10. The Illinois Public Aid Code is amended by
7changing Section 5-5 as follows:
8    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
9    Sec. 5-5. Medical services. The Illinois Department, by
10rule, shall determine the quantity and quality of and the rate
11of reimbursement for the medical assistance for which payment
12will be authorized, and the medical services to be provided,
13which may include all or part of the following: (1) inpatient
14hospital services; (2) outpatient hospital services; (3) other
15laboratory and X-ray services; (4) skilled nursing home
16services; (5) physicians' services whether furnished in the
17office, the patient's home, a hospital, a skilled nursing
18home, or elsewhere; (6) medical care, or any other type of
19remedial care furnished by licensed practitioners; (7) home
20health care services; (8) private duty nursing service; (9)
21clinic services; (10) dental services, including prevention
22and treatment of periodontal disease and dental caries disease
23for pregnant individuals, provided by an individual licensed
24to practice dentistry or dental surgery; for purposes of this



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1item (10), "dental services" means diagnostic, preventive, or
2corrective procedures provided by or under the supervision of
3a dentist in the practice of his or her profession; (11)
4physical therapy and related services; (12) prescribed drugs,
5dentures, and prosthetic devices; and eyeglasses prescribed by
6a physician skilled in the diseases of the eye, or by an
7optometrist, whichever the person may select; (13) other
8diagnostic, screening, preventive, and rehabilitative
9services, including to ensure that the individual's need for
10intervention or treatment of mental disorders or substance use
11disorders or co-occurring mental health and substance use
12disorders is determined using a uniform screening, assessment,
13and evaluation process inclusive of criteria, for children and
14adults; for purposes of this item (13), a uniform screening,
15assessment, and evaluation process refers to a process that
16includes an appropriate evaluation and, as warranted, a
17referral; "uniform" does not mean the use of a singular
18instrument, tool, or process that all must utilize; (14)
19transportation and such other expenses as may be necessary;
20(15) medical treatment of sexual assault survivors, as defined
21in Section 1a of the Sexual Assault Survivors Emergency
22Treatment Act, for injuries sustained as a result of the
23sexual assault, including examinations and laboratory tests to
24discover evidence which may be used in criminal proceedings
25arising from the sexual assault; (16) the diagnosis and
26treatment of sickle cell anemia; (16.5) services performed by



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1a chiropractic physician licensed under the Medical Practice
2Act of 1987 and acting within the scope of his or her license,
3including, but not limited to, chiropractic manipulative
4treatment; and (17) any other medical care, and any other type
5of remedial care recognized under the laws of this State. The
6term "any other type of remedial care" shall include nursing
7care and nursing home service for persons who rely on
8treatment by spiritual means alone through prayer for healing.
9    Notwithstanding any other provision of this Section, a
10comprehensive tobacco use cessation program that includes
11purchasing prescription drugs or prescription medical devices
12approved by the Food and Drug Administration shall be covered
13under the medical assistance program under this Article for
14persons who are otherwise eligible for assistance under this
16    Notwithstanding any other provision of this Code,
17reproductive health care that is otherwise legal in Illinois
18shall be covered under the medical assistance program for
19persons who are otherwise eligible for medical assistance
20under this Article.
21    Notwithstanding any other provision of this Section, all
22tobacco cessation medications approved by the United States
23Food and Drug Administration and all individual and group
24tobacco cessation counseling services and telephone-based
25counseling services and tobacco cessation medications provided
26through the Illinois Tobacco Quitline shall be covered under



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1the medical assistance program for persons who are otherwise
2eligible for assistance under this Article. The Department
3shall comply with all federal requirements necessary to obtain
4federal financial participation, as specified in 42 CFR
5433.15(b)(7), for telephone-based counseling services provided
6through the Illinois Tobacco Quitline, including, but not
7limited to: (i) entering into a memorandum of understanding or
8interagency agreement with the Department of Public Health, as
9administrator of the Illinois Tobacco Quitline; and (ii)
10developing a cost allocation plan for Medicaid-allowable
11Illinois Tobacco Quitline services in accordance with 45 CFR
1295.507. The Department shall submit the memorandum of
13understanding or interagency agreement, the cost allocation
14plan, and all other necessary documentation to the Centers for
15Medicare and Medicaid Services for review and approval.
16Coverage under this paragraph shall be contingent upon federal
18    Notwithstanding any other provision of this Code, the
19Illinois Department may not require, as a condition of payment
20for any laboratory test authorized under this Article, that a
21physician's handwritten signature appear on the laboratory
22test order form. The Illinois Department may, however, impose
23other appropriate requirements regarding laboratory test order
25    Upon receipt of federal approval of an amendment to the
26Illinois Title XIX State Plan for this purpose, the Department



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



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1    the person may select.
2    On and after July 1, 2018, the Department of Healthcare
3and Family Services shall provide dental services to any adult
4who is otherwise eligible for assistance under the medical
5assistance program. As used in this paragraph, "dental
6services" means diagnostic, preventative, restorative, or
7corrective procedures, including procedures and services for
8the prevention and treatment of periodontal disease and dental
9caries disease, provided by an individual who is licensed to
10practice dentistry or dental surgery or who is under the
11supervision of a dentist in the practice of his or her
13    On and after July 1, 2018, targeted dental services, as
14set forth in Exhibit D of the Consent Decree entered by the
15United States District Court for the Northern District of
16Illinois, Eastern Division, in the matter of Memisovski v.
17Maram, Case No. 92 C 1982, that are provided to adults under
18the medical assistance program shall be established at no less
19than the rates set forth in the "New Rate" column in Exhibit D
20of the Consent Decree for targeted dental services that are
21provided to persons under the age of 18 under the medical
22assistance program.
23    Notwithstanding any other provision of this Code and
24subject to federal approval, the Department may adopt rules to
25allow a dentist who is volunteering his or her service at no
26cost to render dental services through an enrolled



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1not-for-profit health clinic without the dentist personally
2enrolling as a participating provider in the medical
3assistance program. A not-for-profit health clinic shall
4include a public health clinic or Federally Qualified Health
5Center or other enrolled provider, as determined by the
6Department, through which dental services covered under this
7Section are performed. The Department shall establish a
8process for payment of claims for reimbursement for covered
9dental services rendered under this provision.
10    On and after January 1, 2022, the Department of Healthcare
11and Family Services shall administer and regulate a
12school-based dental program that allows for the out-of-office
13delivery of preventative dental services in a school setting
14to children under 19 years of age. The Department shall
15establish, by rule, guidelines for participation by providers
16and set requirements for follow-up referral care based on the
17requirements established in the Dental Office Reference Manual
18published by the Department that establishes the requirements
19for dentists participating in the All Kids Dental School
20Program. Every effort shall be made by the Department when
21developing the program requirements to consider the different
22geographic differences of both urban and rural areas of the
23State for initial treatment and necessary follow-up care. No
24provider shall be charged a fee by any unit of local government
25to participate in the school-based dental program administered
26by the Department. Nothing in this paragraph shall be



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1construed to limit or preempt a home rule unit's or school
2district's authority to establish, change, or administer a
3school-based dental program in addition to, or independent of,
4the school-based dental program administered by the
6    The Illinois Department, by rule, may distinguish and
7classify the medical services to be provided only in
8accordance with the classes of persons designated in Section
10    The Department of Healthcare and Family Services must
11provide coverage and reimbursement for amino acid-based
12elemental formulas, regardless of delivery method, for the
13diagnosis and treatment of (i) eosinophilic disorders and (ii)
14short bowel syndrome when the prescribing physician has issued
15a written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for
20individuals 35 years of age or older who are eligible for
21medical assistance under this Article, as follows:
22        (A) A baseline mammogram for individuals 35 to 39
23    years of age.
24        (B) An annual mammogram for individuals 40 years of
25    age or older.
26        (C) A mammogram at the age and intervals considered



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



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



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1Register or issues an opinion, guidance, or other action that
2would require the State, pursuant to any provision of the
3Patient Protection and Affordable Care Act (Public Law
4111-148), including, but not limited to, 42 U.S.C.
518031(d)(3)(B) or any successor provision, to defray the cost
6of any coverage for breast tomosynthesis outlined in this
7paragraph, then the requirement that an insurer cover breast
8tomosynthesis is inoperative other than any such coverage
9authorized under Section 1902 of the Social Security Act, 42
10U.S.C. 1396a, and the State shall not assume any obligation
11for the cost of coverage for breast tomosynthesis set forth in
12this paragraph.
13    On and after January 1, 2016, the Department shall ensure
14that all networks of care for adult clients of the Department
15include access to at least one breast imaging Center of
16Imaging Excellence as certified by the American College of
18    On and after January 1, 2012, providers participating in a
19quality improvement program approved by the Department shall
20be reimbursed for screening and diagnostic mammography at the
21same rate as the Medicare program's rates, including the
22increased reimbursement for digital mammography.
23    The Department shall convene an expert panel including
24representatives of hospitals, free-standing mammography
25facilities, and doctors, including radiologists, to establish
26quality standards for mammography.



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



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



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1Department shall require all networks of care to include
2access for patients diagnosed with cancer to at least one
3academic commission on cancer-accredited cancer program as an
4in-network covered benefit.
5    On or after July 1, 2022, individuals who are otherwise
6eligible for medical assistance under this Article shall
7receive coverage for perinatal depression screenings for the
812-month period beginning on the last day of their pregnancy.
9Medical assistance coverage under this paragraph shall be
10conditioned on the use of a screening instrument approved by
11the Department.
12    Any medical or health care provider shall immediately
13recommend, to any pregnant individual who is being provided
14prenatal services and is suspected of having a substance use
15disorder as defined in the Substance Use Disorder Act,
16referral to a local substance use disorder treatment program
17licensed by the Department of Human Services or to a licensed
18hospital which provides substance abuse treatment services.
19The Department of Healthcare and Family Services shall assure
20coverage for the cost of treatment of the drug abuse or
21addiction for pregnant recipients in accordance with the
22Illinois Medicaid Program in conjunction with the Department
23of Human Services.
24    All medical providers providing medical assistance to
25pregnant individuals under this Code shall receive information
26from the Department on the availability of services under any



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



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



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



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1    The Illinois Department shall require health care
2providers to maintain records that document the medical care
3and services provided to recipients of Medical Assistance
4under this Article. Such records must be retained for a period
5of not less than 6 years from the date of service or as
6provided by applicable State law, whichever period is longer,
7except that if an audit is initiated within the required
8retention period then the records must be retained until the
9audit is completed and every exception is resolved. The
10Illinois Department shall require health care providers to
11make available, when authorized by the patient, in writing,
12the medical records in a timely fashion to other health care
13providers who are treating or serving persons eligible for
14Medical Assistance under this Article. All dispensers of
15medical services shall be required to maintain and retain
16business and professional records sufficient to fully and
17accurately document the nature, scope, details and receipt of
18the health care provided to persons eligible for medical
19assistance under this Code, in accordance with regulations
20promulgated by the Illinois Department. The rules and
21regulations shall require that proof of the receipt of
22prescription drugs, dentures, prosthetic devices and
23eyeglasses by eligible persons under this Section accompany
24each claim for reimbursement submitted by the dispenser of
25such medical services. No such claims for reimbursement shall
26be approved for payment by the Illinois Department without



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1such proof of receipt, unless the Illinois Department shall
2have put into effect and shall be operating a system of
3post-payment audit and review which shall, on a sampling
4basis, be deemed adequate by the Illinois Department to assure
5that such drugs, dentures, prosthetic devices and eyeglasses
6for which payment is being made are actually being received by
7eligible recipients. Within 90 days after September 16, 1984
8(the effective date of Public Act 83-1439), the Illinois
9Department shall establish a current list of acquisition costs
10for all prosthetic devices and any other items recognized as
11medical equipment and supplies reimbursable under this Article
12and shall update such list on a quarterly basis, except that
13the acquisition costs of all prescription drugs shall be
14updated no less frequently than every 30 days as required by
15Section 5-5.12.
16    Notwithstanding any other law to the contrary, the
17Illinois Department shall, within 365 days after July 22, 2013
18(the effective date of Public Act 98-104), establish
19procedures to permit skilled care facilities licensed under
20the Nursing Home Care Act to submit monthly billing claims for
21reimbursement purposes. Following development of these
22procedures, the Department shall, by July 1, 2016, test the
23viability of the new system and implement any necessary
24operational or structural changes to its information
25technology platforms in order to allow for the direct
26acceptance and payment of nursing home claims.



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1    Notwithstanding any other law to the contrary, the
2Illinois Department shall, within 365 days after August 15,
32014 (the effective date of Public Act 98-963), establish
4procedures to permit ID/DD facilities licensed under the ID/DD
5Community Care Act and MC/DD facilities licensed under the
6MC/DD Act to submit monthly billing claims for reimbursement
7purposes. Following development of these procedures, the
8Department shall have an additional 365 days to test the
9viability of the new system and to ensure that any necessary
10operational or structural changes to its information
11technology platforms are implemented.
12    The Illinois Department shall require all dispensers of
13medical services, other than an individual practitioner or
14group of practitioners, desiring to participate in the Medical
15Assistance program established under this Article to disclose
16all financial, beneficial, ownership, equity, surety or other
17interests in any and all firms, corporations, partnerships,
18associations, business enterprises, joint ventures, agencies,
19institutions or other legal entities providing any form of
20health care services in this State under this Article.
21    The Illinois Department may require that all dispensers of
22medical services desiring to participate in the medical
23assistance program established under this Article disclose,
24under such terms and conditions as the Illinois Department may
25by rule establish, all inquiries from clients and attorneys
26regarding medical bills paid by the Illinois Department, which



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



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



HB4408- 24 -LRB102 22908 KTG 32061 b

1    until the provider has been notified of the error.
2        (3) In the case of a provider for whom the Illinois
3    Department initiates the monthly billing process.
4        (4) In the case of a provider operated by a unit of
5    local government with a population exceeding 3,000,000
6    when local government funds finance federal participation
7    for claims payments.
8    For claims for services rendered during a period for which
9a recipient received retroactive eligibility, claims must be
10filed within 180 days after the Department determines the
11applicant is eligible. For claims for which the Illinois
12Department is not the primary payer, claims must be submitted
13to the Illinois Department within 180 days after the final
14adjudication by the primary payer.
15    In the case of long term care facilities, within 120
16calendar days of receipt by the facility of required
17prescreening information, new admissions with associated
18admission documents shall be submitted through the Medical
19Electronic Data Interchange (MEDI) or the Recipient
20Eligibility Verification (REV) System or shall be submitted
21directly to the Department of Human Services using required
22admission forms. Effective September 1, 2014, admission
23documents, including all prescreening information, must be
24submitted through MEDI or REV. Confirmation numbers assigned
25to an accepted transaction shall be retained by a facility to
26verify timely submittal. Once an admission transaction has



HB4408- 25 -LRB102 22908 KTG 32061 b

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



HB4408- 26 -LRB102 22908 KTG 32061 b

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



HB4408- 27 -LRB102 22908 KTG 32061 b

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



HB4408- 28 -LRB102 22908 KTG 32061 b

1recipients. No later than 15 months after the effective date
2of the rule adopted pursuant to this paragraph, all providers
3must meet the accreditation requirement.
4    In order to promote environmental responsibility, meet the
5needs of recipients and enrollees, and achieve significant
6cost savings, the Department, or a managed care organization
7under contract with the Department, may provide recipients or
8managed care enrollees who have a prescription or Certificate
9of Medical Necessity access to refurbished durable medical
10equipment under this Section (excluding prosthetic and
11orthotic devices as defined in the Orthotics, Prosthetics, and
12Pedorthics Practice Act and complex rehabilitation technology
13products and associated services) through the State's
14assistive technology program's reutilization program, using
15staff with the Assistive Technology Professional (ATP)
16Certification if the refurbished durable medical equipment:
17(i) is available; (ii) is less expensive, including shipping
18costs, than new durable medical equipment of the same type;
19(iii) is able to withstand at least 3 years of use; (iv) is
20cleaned, disinfected, sterilized, and safe in accordance with
21federal Food and Drug Administration regulations and guidance
22governing the reprocessing of medical devices in health care
23settings; and (v) equally meets the needs of the recipient or
24enrollee. The reutilization program shall confirm that the
25recipient or enrollee is not already in receipt of the same or
26similar equipment from another service provider, and that the



HB4408- 29 -LRB102 22908 KTG 32061 b

1refurbished durable medical equipment equally meets the needs
2of the recipient or enrollee. Nothing in this paragraph shall
3be construed to limit recipient or enrollee choice to obtain
4new durable medical equipment or place any additional prior
5authorization conditions on enrollees of managed care
7    The Department shall execute, relative to the nursing home
8prescreening project, written inter-agency agreements with the
9Department of Human Services and the Department on Aging, to
10effect the following: (i) intake procedures and common
11eligibility criteria for those persons who are receiving
12non-institutional services; and (ii) the establishment and
13development of non-institutional services in areas of the
14State where they are not currently available or are
15undeveloped; and (iii) notwithstanding any other provision of
16law, subject to federal approval, on and after July 1, 2012, an
17increase in the determination of need (DON) scores from 29 to
1837 for applicants for institutional and home and
19community-based long term care; if and only if federal
20approval is not granted, the Department may, in conjunction
21with other affected agencies, implement utilization controls
22or changes in benefit packages to effectuate a similar savings
23amount for this population; and (iv) no later than July 1,
242013, minimum level of care eligibility criteria for
25institutional and home and community-based long term care; and
26(v) no later than October 1, 2013, establish procedures to



HB4408- 30 -LRB102 22908 KTG 32061 b

1permit long term care providers access to eligibility scores
2for individuals with an admission date who are seeking or
3receiving services from the long term care provider. In order
4to select the minimum level of care eligibility criteria, the
5Governor shall establish a workgroup that includes affected
6agency representatives and stakeholders representing the
7institutional and home and community-based long term care
8interests. This Section shall not restrict the Department from
9implementing lower level of care eligibility criteria for
10community-based services in circumstances where federal
11approval has been granted.
12    The Illinois Department shall develop and operate, in
13cooperation with other State Departments and agencies and in
14compliance with applicable federal laws and regulations,
15appropriate and effective systems of health care evaluation
16and programs for monitoring of utilization of health care
17services and facilities, as it affects persons eligible for
18medical assistance under this Code.
19    The Illinois Department shall report annually to the
20General Assembly, no later than the second Friday in April of
211979 and each year thereafter, in regard to:
22        (a) actual statistics and trends in utilization of
23    medical services by public aid recipients;
24        (b) actual statistics and trends in the provision of
25    the various medical services by medical vendors;
26        (c) current rate structures and proposed changes in



HB4408- 31 -LRB102 22908 KTG 32061 b

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



HB4408- 32 -LRB102 22908 KTG 32061 b

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



HB4408- 33 -LRB102 22908 KTG 32061 b

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



HB4408- 34 -LRB102 22908 KTG 32061 b

1    A federally qualified health center, as defined in Section
21905(l)(2)(B) of the federal Social Security Act, shall be
3reimbursed by the Department in accordance with the federally
4qualified health center's encounter rate for services provided
5to medical assistance recipients that are performed by a
6dental hygienist, as defined under the Illinois Dental
7Practice Act, working under the general supervision of a
8dentist and employed by a federally qualified health center.
9    Within 90 days after October 8, 2021 (the effective date
10of Public Act 102-665) this amendatory Act of the 102nd
11General Assembly, the Department shall seek federal approval
12of a State Plan amendment to expand coverage for family
13planning services that includes presumptive eligibility to
14individuals whose income is at or below 208% of the federal
15poverty level. Coverage under this Section shall be effective
16beginning no later than December 1, 2022.
17    Subject to approval by the federal Centers for Medicare
18and Medicaid Services of a Title XIX State Plan amendment
19electing the Program of All-Inclusive Care for the Elderly
20(PACE) as a State Medicaid option, as provided for by Subtitle
21I (commencing with Section 4801) of Title IV of the Balanced
22Budget Act of 1997 (Public Law 105-33) and Part 460
23(commencing with Section 460.2) of Subchapter E of Title 42 of
24the Code of Federal Regulations, PACE program services shall
25become a covered benefit of the medical assistance program,
26subject to criteria established in accordance with all



HB4408- 35 -LRB102 22908 KTG 32061 b

1applicable laws.
2    Notwithstanding any other provision of this Code,
3community-based pediatric palliative care from a trained
4interdisciplinary team shall be covered under the medical
5assistance program as provided in Section 15 of the Pediatric
6Palliative Care Act.
7(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
8102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
935, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1055-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
11102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
121-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)