Full Text of SB0967 102nd General Assembly
SB0967enr 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning health.
| 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly:
| 4 | | Section 1. This Act may be referred to as the Improving | 5 | | Health Care for Pregnant and Postpartum Individuals Act. | 6 | | Section 5. The State Employees Group Insurance Act of 1971 | 7 | | is amended by changing Section 6.11 as follows:
| 8 | | (5 ILCS 375/6.11)
| 9 | | Sec. 6.11. Required health benefits; Illinois Insurance | 10 | | Code
requirements. The program of health
benefits shall | 11 | | provide the post-mastectomy care benefits required to be | 12 | | covered
by a policy of accident and health insurance under | 13 | | Section 356t of the Illinois
Insurance Code. The program of | 14 | | health benefits shall provide the coverage
required under | 15 | | Sections 356g, 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, | 16 | | 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | 17 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, | 18 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | 19 | | 356z.36, 356z.40, and 356z.41 of the
Illinois Insurance Code.
| 20 | | The program of health benefits must comply with Sections | 21 | | 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article | 22 | | XXXIIB of the
Illinois Insurance Code. The Department of |
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| 1 | | Insurance shall enforce the requirements of this Section with | 2 | | respect to Sections 370c and 370c.1 of the Illinois Insurance | 3 | | Code; all other requirements of this Section shall be enforced | 4 | | by the Department of Central Management Services.
| 5 | | Rulemaking authority to implement Public Act 95-1045, if | 6 | | any, is conditioned on the rules being adopted in accordance | 7 | | with all provisions of the Illinois Administrative Procedure | 8 | | Act and all rules and procedures of the Joint Committee on | 9 | | Administrative Rules; any purported rule not so adopted, for | 10 | | whatever reason, is unauthorized. | 11 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 12 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 13 | | 1-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13, | 14 | | eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | 15 | | 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff. | 16 | | 1-1-21 .) | 17 | | Section 10. The Department of Human Services Act is | 18 | | amended by adding Section 10-23 as follows: | 19 | | (20 ILCS 1305/10-23 new) | 20 | | Sec. 10-23. High-risk pregnant or postpartum individuals. | 21 | | The Department shall expand and update its maternal child | 22 | | health programs to serve pregnant and postpartum individuals | 23 | | determined to be high-risk using criteria established by a | 24 | | multi-agency working group. The services shall be provided by |
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| 1 | | registered nurses, licensed social workers, or other staff | 2 | | with behavioral health or medical training, as approved by the | 3 | | Department. The persons providing the services may collaborate | 4 | | with other providers, including, but not limited to, | 5 | | obstetricians, gynecologists, or pediatricians, when providing | 6 | | services to a patient. | 7 | | Section 15. The Department of Public Health Powers and | 8 | | Duties Law of the
Civil Administrative Code of Illinois is | 9 | | amended by renumbering and changing Section 2310-223, as added | 10 | | by Public Act 101-390, and by adding Section 2310-470 as | 11 | | follows: | 12 | | (20 ILCS 2310/2310-222) | 13 | | Sec. 2310-222 2310-223 . Obstetric hemorrhage and | 14 | | hypertension training. | 15 | | (a) As used in this Section : , | 16 | | " Birthing birthing facility" means (1) a hospital, as | 17 | | defined in the Hospital Licensing Act, with more than one | 18 | | licensed obstetric bed or a neonatal intensive care unit; (2) | 19 | | a hospital operated by a State university; or (3) a birth | 20 | | center, as defined in the Alternative Health Care Delivery | 21 | | Act. | 22 | | "Postpartum" means the 12-month period after a person has | 23 | | delivered a baby. | 24 | | (b) The Department shall ensure that all birthing |
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| 1 | | facilities have a written policy and conduct continuing | 2 | | education yearly for providers and staff of obstetric medicine | 3 | | and of the emergency department and other staff that may care | 4 | | for pregnant or postpartum women. The written policy and | 5 | | continuing education shall include yearly educational modules | 6 | | regarding management of severe maternal hypertension and | 7 | | obstetric hemorrhage and other leading causes of maternal | 8 | | mortality for units that care for pregnant or postpartum | 9 | | women. Birthing facilities must demonstrate compliance with | 10 | | these written policy, education , and training requirements. | 11 | | (c) The Department shall collaborate with the Illinois | 12 | | Perinatal Quality Collaborative or its successor organization | 13 | | to develop an initiative to improve birth equity and reduce | 14 | | peripartum racial and ethnic disparities. The Department shall | 15 | | ensure that the initiative includes the development of best | 16 | | practices for implicit bias training and education in cultural | 17 | | competency to be used by birthing facilities in interactions | 18 | | between patients and providers. In developing the initiative, | 19 | | the Illinois Perinatal Quality Collaborative or its successor | 20 | | organization shall consider existing programs, such as the | 21 | | Alliance for Innovation on Maternal Health and the California | 22 | | Maternal Quality Collaborative's pilot work on improving birth | 23 | | equity. The Department shall support the initiation of a | 24 | | statewide perinatal quality improvement initiative in | 25 | | collaboration with birthing facilities to implement strategies | 26 | | to reduce peripartum racial and ethnic disparities and to |
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| 1 | | address implicit bias in the health care system. | 2 | | (d) In order to better facilitate continuity of care, the | 3 | | The Department, in consultation with the Illinois Perinatal | 4 | | Quality Collaborative Maternal Mortality Review Committee , | 5 | | shall make available to all birthing facilities best practices | 6 | | for timely identification and assessment of all pregnant and | 7 | | postpartum women for common pregnancy or postpartum | 8 | | complications in the emergency department and for care | 9 | | provided by the birthing facility throughout the pregnancy and | 10 | | postpartum period. The best practices shall include the | 11 | | appropriate and timely consultation of an obstetric or other | 12 | | relevant provider to provide input on management and | 13 | | follow-up , such as offering coordination of a post-delivery | 14 | | early postpartum visit or other services that may be | 15 | | appropriate and available . Birthing facilities shall | 16 | | incorporate these best practices into the written policy | 17 | | required under subsection (b). Birthing facilities may use | 18 | | telemedicine for the consultation. | 19 | | (e) The Department may adopt rules for the purpose of | 20 | | implementing this Section.
| 21 | | (Source: P.A. 101-390, eff. 1-1-20; revised 10-7-19.) | 22 | | (20 ILCS 2310/2310-470 new) | 23 | | Sec. 2310-470. High Risk Infant Follow-up. The Department, | 24 | | in collaboration with the Department of Human Services, the | 25 | | Department of Healthcare and Family Services, and other key |
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| 1 | | providers of maternal child health services, shall revise or | 2 | | add to the rules of the Maternal and Child Health Services Code | 3 | | (77 Ill. Adm. Code 630) that govern the High Risk Infant | 4 | | Follow-up, using current scientific and national and State | 5 | | outcomes data, to revise or expand existing services to | 6 | | improve both maternal and infant outcomes overall and to | 7 | | reduce racial disparities in outcomes and services provided. | 8 | | The rules shall be revised or adopted on or before June 1, | 9 | | 2024.
| 10 | | Section 20. The Counties Code is amended by changing | 11 | | Section 5-1069.3 as follows: | 12 | | (55 ILCS 5/5-1069.3)
| 13 | | Sec. 5-1069.3. Required health benefits. If a county, | 14 | | including a home
rule
county, is a self-insurer for purposes | 15 | | of providing health insurance coverage
for its employees, the | 16 | | coverage shall include coverage for the post-mastectomy
care | 17 | | benefits required to be covered by a policy of accident and | 18 | | health
insurance under Section 356t and the coverage required | 19 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 20 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 21 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 22 | | 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
| 23 | | the Illinois Insurance Code. The coverage shall comply with | 24 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
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| 1 | | Insurance Code. The Department of Insurance shall enforce the | 2 | | requirements of this Section. The requirement that health | 3 | | benefits be covered
as provided in this Section is an
| 4 | | exclusive power and function of the State and is a denial and | 5 | | limitation under
Article VII, Section 6, subsection (h) of the | 6 | | Illinois Constitution. A home
rule county to which this | 7 | | Section applies must comply with every provision of
this | 8 | | Section.
| 9 | | Rulemaking authority to implement Public Act 95-1045, if | 10 | | any, is conditioned on the rules being adopted in accordance | 11 | | with all provisions of the Illinois Administrative Procedure | 12 | | Act and all rules and procedures of the Joint Committee on | 13 | | Administrative Rules; any purported rule not so adopted, for | 14 | | whatever reason, is unauthorized. | 15 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 16 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 17 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 18 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 19 | | 101-625, eff. 1-1-21 .) | 20 | | Section 25. The Illinois Municipal Code is amended by | 21 | | changing Section 10-4-2.3 as follows: | 22 | | (65 ILCS 5/10-4-2.3)
| 23 | | Sec. 10-4-2.3. Required health benefits. If a | 24 | | municipality, including a
home rule municipality, is a |
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| 1 | | self-insurer for purposes of providing health
insurance | 2 | | coverage for its employees, the coverage shall include | 3 | | coverage for
the post-mastectomy care benefits required to be | 4 | | covered by a policy of
accident and health insurance under | 5 | | Section 356t and the coverage required
under Sections 356g, | 6 | | 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, | 7 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, | 8 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | 9 | | 356z.36, 356z.40, and 356z.41 of the Illinois
Insurance
Code. | 10 | | The coverage shall comply with Sections 155.22a, 355b, | 11 | | 356z.19, and 370c of
the Illinois Insurance Code. The | 12 | | Department of Insurance shall enforce the requirements of this | 13 | | Section. The requirement that health
benefits be covered as | 14 | | provided in this is an exclusive power and function of
the | 15 | | State and is a denial and limitation under Article VII, | 16 | | Section 6,
subsection (h) of the Illinois Constitution. A home | 17 | | rule municipality to which
this Section applies must comply | 18 | | with every provision of this Section.
| 19 | | Rulemaking authority to implement Public Act 95-1045, if | 20 | | any, is conditioned on the rules being adopted in accordance | 21 | | with all provisions of the Illinois Administrative Procedure | 22 | | Act and all rules and procedures of the Joint Committee on | 23 | | Administrative Rules; any purported rule not so adopted, for | 24 | | whatever reason, is unauthorized. | 25 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 26 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
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| 1 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 2 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 3 | | 101-625, eff. 1-1-21 .) | 4 | | Section 30. The School Code is amended by changing Section | 5 | | 10-22.3f as follows: | 6 | | (105 ILCS 5/10-22.3f)
| 7 | | Sec. 10-22.3f. Required health benefits. Insurance | 8 | | protection and
benefits
for employees shall provide the | 9 | | post-mastectomy care benefits required to be
covered by a | 10 | | policy of accident and health insurance under Section 356t and | 11 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 12 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 13 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 14 | | 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
| 15 | | the
Illinois Insurance Code.
Insurance policies shall comply | 16 | | with Section 356z.19 of the Illinois Insurance Code. The | 17 | | coverage shall comply with Sections 155.22a, 355b, and 370c of
| 18 | | the Illinois Insurance Code. The Department of Insurance shall | 19 | | enforce the requirements of this Section.
| 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on | 24 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 3 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 4 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 5 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 6 | | 101-625, eff. 1-1-21 .) | 7 | | Section 35. The Illinois Insurance Code is amended by | 8 | | adding Sections 356z.4b and 356z.40 as follows: | 9 | | (215 ILCS 5/356z.4b new) | 10 | | Sec. 356z.4b. Billing for long-acting reversible | 11 | | contraceptives. | 12 | | (a) In this Section, "long-acting reversible contraceptive | 13 | | device" means any intrauterine device or contraceptive | 14 | | implant. | 15 | | (b) Any individual or group policy of accident and health | 16 | | insurance or qualified health plan that is offered through the | 17 | | health insurance marketplace that is amended, delivered, | 18 | | issued, or renewed on or after the effective date of this | 19 | | amendatory Act of the 102nd General Assembly shall allow | 20 | | hospitals separate reimbursement for a long-acting reversible | 21 | | contraceptive device provided immediately postpartum in the | 22 | | inpatient hospital setting before hospital discharge. The | 23 | | payment shall be made in addition to a bundled or Diagnostic | 24 | | Related Group reimbursement for labor and delivery. |
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| 1 | | (215 ILCS 5/356z.40 new) | 2 | | Sec. 356z.40. Pregnancy and postpartum coverage. | 3 | | (a) An individual or group policy of accident and health | 4 | | insurance or managed care plan amended, delivered, issued, or | 5 | | renewed on or after the effective date of this amendatory Act | 6 | | of the 102nd General Assembly shall provide coverage for | 7 | | pregnancy and newborn care in accordance with 42 U.S.C. | 8 | | 18022(b) regarding essential health benefits. | 9 | | (b) Benefits under this Section shall be as follows: | 10 | | (1) An individual who has been identified as | 11 | | experiencing a high-risk pregnancy by the individual's | 12 | | treating provider shall have access to clinically | 13 | | appropriate case management programs. As used in this | 14 | | subsection, "case management" means a mechanism to | 15 | | coordinate and assure continuity of services, including, | 16 | | but not limited to, health services, social services, and | 17 | | educational services necessary for the individual. "Case | 18 | | management" involves individualized assessment of needs, | 19 | | planning of services, referral, monitoring, and advocacy | 20 | | to assist an individual in gaining access to appropriate | 21 | | services and closure when services are no longer required. | 22 | | "Case management" is an active and collaborative process | 23 | | involving a single qualified case manager, the individual, | 24 | | the individual's family, the providers, and the community. | 25 | | This includes close coordination and involvement with all |
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| 1 | | service providers in the management plan for that | 2 | | individual or family, including assuring that the | 3 | | individual receives the services. As used in this | 4 | | subsection, "high-risk pregnancy" means a pregnancy in | 5 | | which the pregnant or postpartum individual or baby is at | 6 | | an increased risk for poor health or complications during | 7 | | pregnancy or childbirth, including, but not limited to, | 8 | | hypertension disorders, gestational diabetes, and | 9 | | hemorrhage. | 10 | | (2) An individual shall have access to medically | 11 | | necessary treatment of a mental, emotional, nervous, or | 12 | | substance use disorder or condition consistent with the | 13 | | requirements set forth in this Section and in Sections | 14 | | 370c and 370c.1 of this Code. | 15 | | (3) The benefits provided for inpatient and outpatient | 16 | | services for the treatment of a mental, emotional, | 17 | | nervous, or substance use disorder or condition related to | 18 | | pregnancy or postpartum complications shall be provided if | 19 | | determined to be medically necessary, consistent with the | 20 | | requirements of Sections 370c and 370c.1 of this Code. The | 21 | | facility or provider shall notify the insurer of both the | 22 | | admission and the initial treatment plan within 48 hours | 23 | | after admission or initiation of treatment. Nothing in | 24 | | this paragraph shall prevent an insurer from applying | 25 | | concurrent and post-service utilization review of health | 26 | | care services, including review of medical necessity, case |
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| 1 | | management, experimental and investigational treatments, | 2 | | managed care provisions, and other terms and conditions of | 3 | | the insurance policy. | 4 | | (4) The benefits for the first 48 hours of initiation | 5 | | of services for an inpatient admission, detoxification or | 6 | | withdrawal management program, or partial hospitalization | 7 | | admission for the treatment of a mental, emotional, | 8 | | nervous, or substance use disorder or condition related to | 9 | | pregnancy or postpartum complications shall be provided | 10 | | without post-service or concurrent review of medical | 11 | | necessity, as the medical necessity for the first 48 hours | 12 | | of such services shall be determined solely by the covered | 13 | | pregnant or postpartum individual's provider. Nothing in | 14 | | this paragraph shall prevent an insurer from applying | 15 | | concurrent and post-service utilization review, including | 16 | | the review of medical necessity, case management, | 17 | | experimental and investigational treatments, managed care | 18 | | provisions, and other terms and conditions of the | 19 | | insurance policy, of any inpatient admission, | 20 | | detoxification or withdrawal management program admission, | 21 | | or partial hospitalization admission services for the | 22 | | treatment of a mental, emotional, nervous, or substance | 23 | | use disorder or condition related to pregnancy or | 24 | | postpartum complications received 48 hours after the | 25 | | initiation of such services. If an insurer determines that | 26 | | the services are no longer medically necessary, then the |
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| 1 | | covered person shall have the right to external review | 2 | | pursuant to the requirements of the Health Carrier | 3 | | External Review Act. | 4 | | (5) If an insurer determines that continued inpatient | 5 | | care, detoxification or withdrawal management, partial | 6 | | hospitalization, intensive outpatient treatment, or | 7 | | outpatient treatment in a facility is no longer medically | 8 | | necessary, the insurer shall, within 24 hours, provide | 9 | | written notice to the covered pregnant or postpartum | 10 | | individual and the covered pregnant or postpartum | 11 | | individual's provider of its decision and the right to | 12 | | file an expedited internal appeal of the determination. | 13 | | The insurer shall review and make a determination with | 14 | | respect to the internal appeal within 24 hours and | 15 | | communicate such determination to the covered pregnant or | 16 | | postpartum individual and the covered pregnant or | 17 | | postpartum individual's provider. If the determination is | 18 | | to uphold the denial, the covered pregnant or postpartum | 19 | | individual and the covered pregnant or postpartum | 20 | | individual's provider have the right to file an expedited | 21 | | external appeal. An independent utilization review | 22 | | organization shall make a determination within 72 hours. | 23 | | If the insurer's determination is upheld and it is | 24 | | determined that continued inpatient care, detoxification | 25 | | or withdrawal management, partial hospitalization, | 26 | | intensive outpatient treatment, or outpatient treatment is |
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| 1 | | not medically necessary, the insurer shall remain | 2 | | responsible for providing benefits for the inpatient care, | 3 | | detoxification or withdrawal management, partial | 4 | | hospitalization, intensive outpatient treatment, or | 5 | | outpatient treatment through the day following the date | 6 | | the determination is made, and the covered pregnant or | 7 | | postpartum individual shall only be responsible for any | 8 | | applicable copayment, deductible, and coinsurance for the | 9 | | stay through that date as applicable under the policy. The | 10 | | covered pregnant or postpartum individual shall not be | 11 | | discharged or released from the inpatient facility, | 12 | | detoxification or withdrawal management, partial | 13 | | hospitalization, intensive outpatient treatment, or | 14 | | outpatient treatment until all internal appeals and | 15 | | independent utilization review organization appeals are | 16 | | exhausted. A decision to reverse an adverse determination | 17 | | shall comply with the Health Carrier External Review Act. | 18 | | (6) Except as otherwise stated in this subsection (b), | 19 | | the benefits and cost-sharing shall be provided to the | 20 | | same extent as for any other medical condition covered | 21 | | under the policy. | 22 | | (7) The benefits required by paragraphs (2) and (6) of | 23 | | this subsection (b) are to be provided to all covered | 24 | | pregnant or postpartum individuals with a diagnosis of a | 25 | | mental, emotional, nervous, or substance use disorder or | 26 | | condition. The presence of additional related or unrelated |
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| 1 | | diagnoses shall not be a basis to reduce or deny the | 2 | | benefits required by this subsection (b). | 3 | | Section 40. The Health Maintenance Organization Act is | 4 | | amended by changing Section 5-3 as follows:
| 5 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 6 | | Sec. 5-3. Insurance Code provisions.
| 7 | | (a) Health Maintenance Organizations
shall be subject to | 8 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 9 | | 141.1,
141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, | 10 | | 154, 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, | 11 | | 355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, | 12 | | 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 13 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, | 14 | | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | 15 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.40, | 16 | | 356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 17 | | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, | 18 | | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | 19 | | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | 20 | | XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois | 21 | | Insurance Code.
| 22 | | (b) For purposes of the Illinois Insurance Code, except | 23 | | for Sections 444
and 444.1 and Articles XIII and XIII 1/2, | 24 | | Health Maintenance Organizations in
the following categories |
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| 1 | | are deemed to be "domestic companies":
| 2 | | (1) a corporation authorized under the
Dental Service | 3 | | Plan Act or the Voluntary Health Services Plans Act;
| 4 | | (2) a corporation organized under the laws of this | 5 | | State; or
| 6 | | (3) a corporation organized under the laws of another | 7 | | state, 30% or more
of the enrollees of which are residents | 8 | | of this State, except a
corporation subject to | 9 | | substantially the same requirements in its state of
| 10 | | organization as is a "domestic company" under Article VIII | 11 | | 1/2 of the
Illinois Insurance Code.
| 12 | | (c) In considering the merger, consolidation, or other | 13 | | acquisition of
control of a Health Maintenance Organization | 14 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 15 | | (1) the Director shall give primary consideration to | 16 | | the continuation of
benefits to enrollees and the | 17 | | financial conditions of the acquired Health
Maintenance | 18 | | Organization after the merger, consolidation, or other
| 19 | | acquisition of control takes effect;
| 20 | | (2)(i) the criteria specified in subsection (1)(b) of | 21 | | Section 131.8 of
the Illinois Insurance Code shall not | 22 | | apply and (ii) the Director, in making
his determination | 23 | | with respect to the merger, consolidation, or other
| 24 | | acquisition of control, need not take into account the | 25 | | effect on
competition of the merger, consolidation, or | 26 | | other acquisition of control;
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| 1 | | (3) the Director shall have the power to require the | 2 | | following
information:
| 3 | | (A) certification by an independent actuary of the | 4 | | adequacy
of the reserves of the Health Maintenance | 5 | | Organization sought to be acquired;
| 6 | | (B) pro forma financial statements reflecting the | 7 | | combined balance
sheets of the acquiring company and | 8 | | the Health Maintenance Organization sought
to be | 9 | | acquired as of the end of the preceding year and as of | 10 | | a date 90 days
prior to the acquisition, as well as pro | 11 | | forma financial statements
reflecting projected | 12 | | combined operation for a period of 2 years;
| 13 | | (C) a pro forma business plan detailing an | 14 | | acquiring party's plans with
respect to the operation | 15 | | of the Health Maintenance Organization sought to
be | 16 | | acquired for a period of not less than 3 years; and
| 17 | | (D) such other information as the Director shall | 18 | | require.
| 19 | | (d) The provisions of Article VIII 1/2 of the Illinois | 20 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 21 | | any health maintenance
organization of greater than 10% of its
| 22 | | enrollee population (including without limitation the health | 23 | | maintenance
organization's right, title, and interest in and | 24 | | to its health care
certificates).
| 25 | | (e) In considering any management contract or service | 26 | | agreement subject
to Section 141.1 of the Illinois Insurance |
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| 1 | | Code, the Director (i) shall, in
addition to the criteria | 2 | | specified in Section 141.2 of the Illinois
Insurance Code, | 3 | | take into account the effect of the management contract or
| 4 | | service agreement on the continuation of benefits to enrollees | 5 | | and the
financial condition of the health maintenance | 6 | | organization to be managed or
serviced, and (ii) need not take | 7 | | into account the effect of the management
contract or service | 8 | | agreement on competition.
| 9 | | (f) Except for small employer groups as defined in the | 10 | | Small Employer
Rating, Renewability and Portability Health | 11 | | Insurance Act and except for
medicare supplement policies as | 12 | | defined in Section 363 of the Illinois
Insurance Code, a | 13 | | Health Maintenance Organization may by contract agree with a
| 14 | | group or other enrollment unit to effect refunds or charge | 15 | | additional premiums
under the following terms and conditions:
| 16 | | (i) the amount of, and other terms and conditions with | 17 | | respect to, the
refund or additional premium are set forth | 18 | | in the group or enrollment unit
contract agreed in advance | 19 | | of the period for which a refund is to be paid or
| 20 | | additional premium is to be charged (which period shall | 21 | | not be less than one
year); and
| 22 | | (ii) the amount of the refund or additional premium | 23 | | shall not exceed 20%
of the Health Maintenance | 24 | | Organization's profitable or unprofitable experience
with | 25 | | respect to the group or other enrollment unit for the | 26 | | period (and, for
purposes of a refund or additional |
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| 1 | | premium, the profitable or unprofitable
experience shall | 2 | | be calculated taking into account a pro rata share of the
| 3 | | Health Maintenance Organization's administrative and | 4 | | marketing expenses, but
shall not include any refund to be | 5 | | made or additional premium to be paid
pursuant to this | 6 | | subsection (f)). The Health Maintenance Organization and | 7 | | the
group or enrollment unit may agree that the profitable | 8 | | or unprofitable
experience may be calculated taking into | 9 | | account the refund period and the
immediately preceding 2 | 10 | | plan years.
| 11 | | The Health Maintenance Organization shall include a | 12 | | statement in the
evidence of coverage issued to each enrollee | 13 | | describing the possibility of a
refund or additional premium, | 14 | | and upon request of any group or enrollment unit,
provide to | 15 | | the group or enrollment unit a description of the method used | 16 | | to
calculate (1) the Health Maintenance Organization's | 17 | | profitable experience with
respect to the group or enrollment | 18 | | unit and the resulting refund to the group
or enrollment unit | 19 | | or (2) the Health Maintenance Organization's unprofitable
| 20 | | experience with respect to the group or enrollment unit and | 21 | | the resulting
additional premium to be paid by the group or | 22 | | enrollment unit.
| 23 | | In no event shall the Illinois Health Maintenance | 24 | | Organization
Guaranty Association be liable to pay any | 25 | | contractual obligation of an
insolvent organization to pay any | 26 | | refund authorized under this Section.
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| 1 | | (g) Rulemaking authority to implement Public Act 95-1045, | 2 | | if any, is conditioned on the rules being adopted in | 3 | | accordance with all provisions of the Illinois Administrative | 4 | | Procedure Act and all rules and procedures of the Joint | 5 | | Committee on Administrative Rules; any purported rule not so | 6 | | adopted, for whatever reason, is unauthorized. | 7 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 8 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 9 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 10 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | 11 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | 12 | | 1-1-20; 101-625, eff. 1-1-21 .) | 13 | | Section 45. The Voluntary Health Services Plans Act is | 14 | | amended by changing Section 10 as follows:
| 15 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 16 | | Sec. 10. Application of Insurance Code provisions. Health | 17 | | services
plan corporations and all persons interested therein | 18 | | or dealing therewith
shall be subject to the provisions of | 19 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 20 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | 21 | | 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, | 22 | | 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | 23 | | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | 24 | | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, |
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| 1 | | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.40, 356z.41, 364.01, | 2 | | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | 3 | | and paragraphs (7) and (15) of Section 367 of the Illinois
| 4 | | Insurance Code.
| 5 | | Rulemaking authority to implement Public Act 95-1045, if | 6 | | any, is conditioned on the rules being adopted in accordance | 7 | | with all provisions of the Illinois Administrative Procedure | 8 | | Act and all rules and procedures of the Joint Committee on | 9 | | Administrative Rules; any purported rule not so adopted, for | 10 | | whatever reason, is unauthorized. | 11 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 12 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 13 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 14 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | 15 | | 101-625, eff. 1-1-21 .) | 16 | | Section 50. The Illinois Public Aid Code is amended by | 17 | | changing Sections 5-2, 5-5, and 5-5.24 and by adding Section | 18 | | 5-18.10 as follows:
| 19 | | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| 20 | | Sec. 5-2. Classes of persons eligible. Medical assistance | 21 | | under this
Article shall be available to any of the following | 22 | | classes of persons in
respect to whom a plan for coverage has | 23 | | been submitted to the Governor
by the Illinois Department and | 24 | | approved by him. If changes made in this Section 5-2 require |
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| 1 | | federal approval, they shall not take effect until such | 2 | | approval has been received:
| 3 | | 1. Recipients of basic maintenance grants under | 4 | | Articles III and IV.
| 5 | | 2. Beginning January 1, 2014, persons otherwise | 6 | | eligible for basic maintenance under Article
III, | 7 | | excluding any eligibility requirements that are | 8 | | inconsistent with any federal law or federal regulation, | 9 | | as interpreted by the U.S. Department of Health and Human | 10 | | Services, but who fail to qualify thereunder on the basis | 11 | | of need, and
who have insufficient income and resources to | 12 | | meet the costs of
necessary medical care, including , but | 13 | | not limited to , the following:
| 14 | | (a) All persons otherwise eligible for basic | 15 | | maintenance under Article
III but who fail to qualify | 16 | | under that Article on the basis of need and who
meet | 17 | | either of the following requirements:
| 18 | | (i) their income, as determined by the | 19 | | Illinois Department in
accordance with any federal | 20 | | requirements, is equal to or less than 100% of the | 21 | | federal poverty level; or
| 22 | | (ii) their income, after the deduction of | 23 | | costs incurred for medical
care and for other | 24 | | types of remedial care, is equal to or less than | 25 | | 100% of the federal poverty level.
| 26 | | (b) (Blank).
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| 1 | | 3. (Blank).
| 2 | | 4. Persons not eligible under any of the preceding | 3 | | paragraphs who fall
sick, are injured, or die, not having | 4 | | sufficient money, property or other
resources to meet the | 5 | | costs of necessary medical care or funeral and burial
| 6 | | expenses.
| 7 | | 5.(a) Beginning January 1, 2020, individuals women | 8 | | during pregnancy and during the
12-month period beginning | 9 | | on the last day of the pregnancy, together with
their | 10 | | infants,
whose income is at or below 200% of the federal | 11 | | poverty level. Until September 30, 2019, or sooner if the | 12 | | maintenance of effort requirements under the Patient | 13 | | Protection and Affordable Care Act are eliminated or may | 14 | | be waived before then, individuals women during pregnancy | 15 | | and during the 12-month period beginning on the last day | 16 | | of the pregnancy, whose countable monthly income, after | 17 | | the deduction of costs incurred for medical care and for | 18 | | other types of remedial care as specified in | 19 | | administrative rule, is equal to or less than the Medical | 20 | | Assistance-No Grant(C) (MANG(C)) Income Standard in effect | 21 | | on April 1, 2013 as set forth in administrative rule.
| 22 | | (b) The plan for coverage shall provide ambulatory | 23 | | prenatal care to pregnant individuals women during a
| 24 | | presumptive eligibility period and establish an income | 25 | | eligibility standard
that is equal to 200% of the federal | 26 | | poverty level, provided that costs incurred
for medical |
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| 1 | | care are not taken into account in determining such income
| 2 | | eligibility.
| 3 | | (c) The Illinois Department may conduct a | 4 | | demonstration in at least one
county that will provide | 5 | | medical assistance to pregnant individuals women, together
| 6 | | with their infants and children up to one year of age,
| 7 | | where the income
eligibility standard is set up to 185% of | 8 | | the nonfarm income official
poverty line, as defined by | 9 | | the federal Office of Management and Budget.
The Illinois | 10 | | Department shall seek and obtain necessary authorization
| 11 | | provided under federal law to implement such a | 12 | | demonstration. Such
demonstration may establish resource | 13 | | standards that are not more
restrictive than those | 14 | | established under Article IV of this Code.
| 15 | | 6. (a) Children younger than age 19 when countable | 16 | | income is at or below 133% of the federal poverty level. | 17 | | Until September 30, 2019, or sooner if the maintenance of | 18 | | effort requirements under the Patient Protection and | 19 | | Affordable Care Act are eliminated or may be waived before | 20 | | then, children younger than age 19 whose countable monthly | 21 | | income, after the deduction of costs incurred for medical | 22 | | care and for other types of remedial care as specified in | 23 | | administrative rule, is equal to or less than the Medical | 24 | | Assistance-No Grant(C) (MANG(C)) Income Standard in effect | 25 | | on April 1, 2013 as set forth in administrative rule. | 26 | | (b) Children and youth who are under temporary custody |
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| 1 | | or guardianship of the Department of Children and Family | 2 | | Services or who receive financial assistance in support of | 3 | | an adoption or guardianship placement from the Department | 4 | | of Children and Family Services.
| 5 | | 7. (Blank).
| 6 | | 8. As required under federal law, persons who are | 7 | | eligible for Transitional Medical Assistance as a result | 8 | | of an increase in earnings or child or spousal support | 9 | | received. The plan for coverage for this class of persons | 10 | | shall:
| 11 | | (a) extend the medical assistance coverage to the | 12 | | extent required by federal law; and
| 13 | | (b) offer persons who have initially received 6 | 14 | | months of the
coverage provided in paragraph (a) | 15 | | above, the option of receiving an
additional 6 months | 16 | | of coverage, subject to the following:
| 17 | | (i) such coverage shall be pursuant to | 18 | | provisions of the federal
Social Security Act;
| 19 | | (ii) such coverage shall include all services | 20 | | covered under Illinois' State Medicaid Plan;
| 21 | | (iii) no premium shall be charged for such | 22 | | coverage; and
| 23 | | (iv) such coverage shall be suspended in the | 24 | | event of a person's
failure without good cause to | 25 | | file in a timely fashion reports required for
this | 26 | | coverage under the Social Security Act and |
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| 1 | | coverage shall be reinstated
upon the filing of | 2 | | such reports if the person remains otherwise | 3 | | eligible.
| 4 | | 9. Persons with acquired immunodeficiency syndrome | 5 | | (AIDS) or with
AIDS-related conditions with respect to | 6 | | whom there has been a determination
that but for home or | 7 | | community-based services such individuals would
require | 8 | | the level of care provided in an inpatient hospital, | 9 | | skilled
nursing facility or intermediate care facility the | 10 | | cost of which is
reimbursed under this Article. Assistance | 11 | | shall be provided to such
persons to the maximum extent | 12 | | permitted under Title
XIX of the Federal Social Security | 13 | | Act.
| 14 | | 10. Participants in the long-term care insurance | 15 | | partnership program
established under the Illinois | 16 | | Long-Term Care Partnership Program Act who meet the
| 17 | | qualifications for protection of resources described in | 18 | | Section 15 of that
Act.
| 19 | | 11. Persons with disabilities who are employed and | 20 | | eligible for Medicaid,
pursuant to Section | 21 | | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, | 22 | | subject to federal approval, persons with a medically | 23 | | improved disability who are employed and eligible for | 24 | | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | 25 | | the Social Security Act, as
provided by the Illinois | 26 | | Department by rule. In establishing eligibility standards |
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| 1 | | under this paragraph 11, the Department shall, subject to | 2 | | federal approval: | 3 | | (a) set the income eligibility standard at not | 4 | | lower than 350% of the federal poverty level; | 5 | | (b) exempt retirement accounts that the person | 6 | | cannot access without penalty before the age
of 59 | 7 | | 1/2, and medical savings accounts established pursuant | 8 | | to 26 U.S.C. 220; | 9 | | (c) allow non-exempt assets up to $25,000 as to | 10 | | those assets accumulated during periods of eligibility | 11 | | under this paragraph 11; and
| 12 | | (d) continue to apply subparagraphs (b) and (c) in | 13 | | determining the eligibility of the person under this | 14 | | Article even if the person loses eligibility under | 15 | | this paragraph 11.
| 16 | | 12. Subject to federal approval, persons who are | 17 | | eligible for medical
assistance coverage under applicable | 18 | | provisions of the federal Social Security
Act and the | 19 | | federal Breast and Cervical Cancer Prevention and | 20 | | Treatment Act of
2000. Those eligible persons are defined | 21 | | to include, but not be limited to,
the following persons:
| 22 | | (1) persons who have been screened for breast or | 23 | | cervical cancer under
the U.S. Centers for Disease | 24 | | Control and Prevention Breast and Cervical Cancer
| 25 | | Program established under Title XV of the federal | 26 | | Public Health Service Services Act in
accordance with |
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| 1 | | the requirements of Section 1504 of that Act as | 2 | | administered by
the Illinois Department of Public | 3 | | Health; and
| 4 | | (2) persons whose screenings under the above | 5 | | program were funded in whole
or in part by funds | 6 | | appropriated to the Illinois Department of Public | 7 | | Health
for breast or cervical cancer screening.
| 8 | | "Medical assistance" under this paragraph 12 shall be | 9 | | identical to the benefits
provided under the State's | 10 | | approved plan under Title XIX of the Social Security
Act. | 11 | | The Department must request federal approval of the | 12 | | coverage under this
paragraph 12 within 30 days after July | 13 | | 3, 2001 ( the effective date of Public Act 92-47) this | 14 | | amendatory Act of
the 92nd General Assembly .
| 15 | | In addition to the persons who are eligible for | 16 | | medical assistance pursuant to subparagraphs (1) and (2) | 17 | | of this paragraph 12, and to be paid from funds | 18 | | appropriated to the Department for its medical programs, | 19 | | any uninsured person as defined by the Department in rules | 20 | | residing in Illinois who is younger than 65 years of age, | 21 | | who has been screened for breast and cervical cancer in | 22 | | accordance with standards and procedures adopted by the | 23 | | Department of Public Health for screening, and who is | 24 | | referred to the Department by the Department of Public | 25 | | Health as being in need of treatment for breast or | 26 | | cervical cancer is eligible for medical assistance |
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| 1 | | benefits that are consistent with the benefits provided to | 2 | | those persons described in subparagraphs (1) and (2). | 3 | | Medical assistance coverage for the persons who are | 4 | | eligible under the preceding sentence is not dependent on | 5 | | federal approval, but federal moneys may be used to pay | 6 | | for services provided under that coverage upon federal | 7 | | approval. | 8 | | 13. Subject to appropriation and to federal approval, | 9 | | persons living with HIV/AIDS who are not otherwise | 10 | | eligible under this Article and who qualify for services | 11 | | covered under Section 5-5.04 as provided by the Illinois | 12 | | Department by rule.
| 13 | | 14. Subject to the availability of funds for this | 14 | | purpose, the Department may provide coverage under this | 15 | | Article to persons who reside in Illinois who are not | 16 | | eligible under any of the preceding paragraphs and who | 17 | | meet the income guidelines of paragraph 2(a) of this | 18 | | Section and (i) have an application for asylum pending | 19 | | before the federal Department of Homeland Security or on | 20 | | appeal before a court of competent jurisdiction and are | 21 | | represented either by counsel or by an advocate accredited | 22 | | by the federal Department of Homeland Security and | 23 | | employed by a not-for-profit organization in regard to | 24 | | that application or appeal, or (ii) are receiving services | 25 | | through a federally funded torture treatment center. | 26 | | Medical coverage under this paragraph 14 may be provided |
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| 1 | | for up to 24 continuous months from the initial | 2 | | eligibility date so long as an individual continues to | 3 | | satisfy the criteria of this paragraph 14. If an | 4 | | individual has an appeal pending regarding an application | 5 | | for asylum before the Department of Homeland Security, | 6 | | eligibility under this paragraph 14 may be extended until | 7 | | a final decision is rendered on the appeal. The Department | 8 | | may adopt rules governing the implementation of this | 9 | | paragraph 14.
| 10 | | 15. Family Care Eligibility. | 11 | | (a) On and after July 1, 2012, a parent or other | 12 | | caretaker relative who is 19 years of age or older when | 13 | | countable income is at or below 133% of the federal | 14 | | poverty level. A person may not spend down to become | 15 | | eligible under this paragraph 15. | 16 | | (b) Eligibility shall be reviewed annually. | 17 | | (c) (Blank). | 18 | | (d) (Blank). | 19 | | (e) (Blank). | 20 | | (f) (Blank). | 21 | | (g) (Blank). | 22 | | (h) (Blank). | 23 | | (i) Following termination of an individual's | 24 | | coverage under this paragraph 15, the individual must | 25 | | be determined eligible before the person can be | 26 | | re-enrolled. |
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| 1 | | 16. Subject to appropriation, uninsured persons who | 2 | | are not otherwise eligible under this Section who have | 3 | | been certified and referred by the Department of Public | 4 | | Health as having been screened and found to need | 5 | | diagnostic evaluation or treatment, or both diagnostic | 6 | | evaluation and treatment, for prostate or testicular | 7 | | cancer. For the purposes of this paragraph 16, uninsured | 8 | | persons are those who do not have creditable coverage, as | 9 | | defined under the Health Insurance Portability and | 10 | | Accountability Act, or have otherwise exhausted any | 11 | | insurance benefits they may have had, for prostate or | 12 | | testicular cancer diagnostic evaluation or treatment, or | 13 | | both diagnostic evaluation and treatment.
To be eligible, | 14 | | a person must furnish a Social Security number.
A person's | 15 | | assets are exempt from consideration in determining | 16 | | eligibility under this paragraph 16.
Such persons shall be | 17 | | eligible for medical assistance under this paragraph 16 | 18 | | for so long as they need treatment for the cancer. A person | 19 | | shall be considered to need treatment if, in the opinion | 20 | | of the person's treating physician, the person requires | 21 | | therapy directed toward cure or palliation of prostate or | 22 | | testicular cancer, including recurrent metastatic cancer | 23 | | that is a known or presumed complication of prostate or | 24 | | testicular cancer and complications resulting from the | 25 | | treatment modalities themselves. Persons who require only | 26 | | routine monitoring services are not considered to need |
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| 1 | | treatment.
"Medical assistance" under this paragraph 16 | 2 | | shall be identical to the benefits provided under the | 3 | | State's approved plan under Title XIX of the Social | 4 | | Security Act.
Notwithstanding any other provision of law, | 5 | | the Department (i) does not have a claim against the | 6 | | estate of a deceased recipient of services under this | 7 | | paragraph 16 and (ii) does not have a lien against any | 8 | | homestead property or other legal or equitable real | 9 | | property interest owned by a recipient of services under | 10 | | this paragraph 16. | 11 | | 17. Persons who, pursuant to a waiver approved by the | 12 | | Secretary of the U.S. Department of Health and Human | 13 | | Services, are eligible for medical assistance under Title | 14 | | XIX or XXI of the federal Social Security Act. | 15 | | Notwithstanding any other provision of this Code and | 16 | | consistent with the terms of the approved waiver, the | 17 | | Illinois Department, may by rule: | 18 | | (a) Limit the geographic areas in which the waiver | 19 | | program operates. | 20 | | (b) Determine the scope, quantity, duration, and | 21 | | quality, and the rate and method of reimbursement, of | 22 | | the medical services to be provided, which may differ | 23 | | from those for other classes of persons eligible for | 24 | | assistance under this Article. | 25 | | (c) Restrict the persons' freedom in choice of | 26 | | providers. |
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| 1 | | 18. Beginning January 1, 2014, persons aged 19 or | 2 | | older, but younger than 65, who are not otherwise eligible | 3 | | for medical assistance under this Section 5-2, who qualify | 4 | | for medical assistance pursuant to 42 U.S.C. | 5 | | 1396a(a)(10)(A)(i)(VIII) and applicable federal | 6 | | regulations, and who have income at or below 133% of the | 7 | | federal poverty level plus 5% for the applicable family | 8 | | size as determined pursuant to 42 U.S.C. 1396a(e)(14) and | 9 | | applicable federal regulations. Persons eligible for | 10 | | medical assistance under this paragraph 18 shall receive | 11 | | coverage for the Health Benefits Service Package as that | 12 | | term is defined in subsection (m) of Section 5-1.1 of this | 13 | | Code. If Illinois' federal medical assistance percentage | 14 | | (FMAP) is reduced below 90% for persons eligible for | 15 | | medical
assistance under this paragraph 18, eligibility | 16 | | under this paragraph 18 shall cease no later than the end | 17 | | of the third month following the month in which the | 18 | | reduction in FMAP takes effect. | 19 | | 19. Beginning January 1, 2014, as required under 42 | 20 | | U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 | 21 | | and younger than age 26 who are not otherwise eligible for | 22 | | medical assistance under paragraphs (1) through (17) of | 23 | | this Section who (i) were in foster care under the | 24 | | responsibility of the State on the date of attaining age | 25 | | 18 or on the date of attaining age 21 when a court has | 26 | | continued wardship for good cause as provided in Section |
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| 1 | | 2-31 of the Juvenile Court Act of 1987 and (ii) received | 2 | | medical assistance under the Illinois Title XIX State Plan | 3 | | or waiver of such plan while in foster care. | 4 | | 20. Beginning January 1, 2018, persons who are | 5 | | foreign-born victims of human trafficking, torture, or | 6 | | other serious crimes as defined in Section 2-19 of this | 7 | | Code and their derivative family members if such persons: | 8 | | (i) reside in Illinois; (ii) are not eligible under any of | 9 | | the preceding paragraphs; (iii) meet the income guidelines | 10 | | of subparagraph (a) of paragraph 2; and (iv) meet the | 11 | | nonfinancial eligibility requirements of Sections 16-2, | 12 | | 16-3, and 16-5 of this Code. The Department may extend | 13 | | medical assistance for persons who are foreign-born | 14 | | victims of human trafficking, torture, or other serious | 15 | | crimes whose medical assistance would be terminated | 16 | | pursuant to subsection (b) of Section 16-5 if the | 17 | | Department determines that the person, during the year of | 18 | | initial eligibility (1) experienced a health crisis, (2) | 19 | | has been unable, after reasonable attempts, to obtain | 20 | | necessary information from a third party, or (3) has other | 21 | | extenuating circumstances that prevented the person from | 22 | | completing his or her application for status. The | 23 | | Department may adopt any rules necessary to implement the | 24 | | provisions of this paragraph. | 25 | | 21. Persons who are not otherwise eligible for medical | 26 | | assistance under this Section who may qualify for medical |
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| 1 | | assistance pursuant to 42 U.S.C. | 2 | | 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the | 3 | | duration of any federal or State declared emergency due to | 4 | | COVID-19. Medical assistance to persons eligible for | 5 | | medical assistance solely pursuant to this paragraph 21 | 6 | | shall be limited to any in vitro diagnostic product (and | 7 | | the administration of such product) described in 42 U.S.C. | 8 | | 1396d(a)(3)(B) on or after March 18, 2020, any visit | 9 | | described in 42 U.S.C. 1396o(a)(2)(G), or any other | 10 | | medical assistance that may be federally authorized for | 11 | | this class of persons. The Department may also cover | 12 | | treatment of COVID-19 for this class of persons, or any | 13 | | similar category of uninsured individuals, to the extent | 14 | | authorized under a federally approved 1115 Waiver or other | 15 | | federal authority. Notwithstanding the provisions of | 16 | | Section 1-11 of this Code, due to the nature of the | 17 | | COVID-19 public health emergency, the Department may cover | 18 | | and provide the medical assistance described in this | 19 | | paragraph 21 to noncitizens who would otherwise meet the | 20 | | eligibility requirements for the class of persons | 21 | | described in this paragraph 21 for the duration of the | 22 | | State emergency period. | 23 | | In implementing the provisions of Public Act 96-20, the | 24 | | Department is authorized to adopt only those rules necessary, | 25 | | including emergency rules. Nothing in Public Act 96-20 permits | 26 | | the Department to adopt rules or issue a decision that expands |
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| 1 | | eligibility for the FamilyCare Program to a person whose | 2 | | income exceeds 185% of the Federal Poverty Level as determined | 3 | | from time to time by the U.S. Department of Health and Human | 4 | | Services, unless the Department is provided with express | 5 | | statutory authority.
| 6 | | The eligibility of any such person for medical assistance | 7 | | under this
Article is not affected by the payment of any grant | 8 | | under the Senior
Citizens and Persons with Disabilities | 9 | | Property Tax Relief Act or any distributions or items of | 10 | | income described under
subparagraph (X) of
paragraph (2) of | 11 | | subsection (a) of Section 203 of the Illinois Income Tax
Act. | 12 | | The Department shall by rule establish the amounts of
| 13 | | assets to be disregarded in determining eligibility for | 14 | | medical assistance,
which shall at a minimum equal the amounts | 15 | | to be disregarded under the
Federal Supplemental Security | 16 | | Income Program. The amount of assets of a
single person to be | 17 | | disregarded
shall not be less than $2,000, and the amount of | 18 | | assets of a married couple
to be disregarded shall not be less | 19 | | than $3,000.
| 20 | | To the extent permitted under federal law, any person | 21 | | found guilty of a
second violation of Article VIIIA
shall be | 22 | | ineligible for medical assistance under this Article, as | 23 | | provided
in Section 8A-8.
| 24 | | The eligibility of any person for medical assistance under | 25 | | this Article
shall not be affected by the receipt by the person | 26 | | of donations or benefits
from fundraisers held for the person |
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| 1 | | in cases of serious illness,
as long as neither the person nor | 2 | | members of the person's family
have actual control over the | 3 | | donations or benefits or the disbursement
of the donations or | 4 | | benefits.
| 5 | | Notwithstanding any other provision of this Code, if the | 6 | | United States Supreme Court holds Title II, Subtitle A, | 7 | | Section 2001(a) of Public Law 111-148 to be unconstitutional, | 8 | | or if a holding of Public Law 111-148 makes Medicaid | 9 | | eligibility allowed under Section 2001(a) inoperable, the | 10 | | State or a unit of local government shall be prohibited from | 11 | | enrolling individuals in the Medical Assistance Program as the | 12 | | result of federal approval of a State Medicaid waiver on or | 13 | | after June 14, 2012 ( the effective date of Public Act 97-687) | 14 | | this amendatory Act of the 97th General Assembly , and any | 15 | | individuals enrolled in the Medical Assistance Program | 16 | | pursuant to eligibility permitted as a result of such a State | 17 | | Medicaid waiver shall become immediately ineligible. | 18 | | Notwithstanding any other provision of this Code, if an | 19 | | Act of Congress that becomes a Public Law eliminates Section | 20 | | 2001(a) of Public Law 111-148, the State or a unit of local | 21 | | government shall be prohibited from enrolling individuals in | 22 | | the Medical Assistance Program as the result of federal | 23 | | approval of a State Medicaid waiver on or after June 14, 2012 | 24 | | ( the effective date of Public Act 97-687) this amendatory Act | 25 | | of the 97th General Assembly , and any individuals enrolled in | 26 | | the Medical Assistance Program pursuant to eligibility |
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| 1 | | permitted as a result of such a State Medicaid waiver shall | 2 | | become immediately ineligible. | 3 | | Effective October 1, 2013, the determination of | 4 | | eligibility of persons who qualify under paragraphs 5, 6, 8, | 5 | | 15, 17, and 18 of this Section shall comply with the | 6 | | requirements of 42 U.S.C. 1396a(e)(14) and applicable federal | 7 | | regulations. | 8 | | The Department of Healthcare and Family Services, the | 9 | | Department of Human Services, and the Illinois health | 10 | | insurance marketplace shall work cooperatively to assist | 11 | | persons who would otherwise lose health benefits as a result | 12 | | of changes made under Public Act 98-104 this amendatory Act of | 13 | | the 98th General Assembly to transition to other health | 14 | | insurance coverage. | 15 | | (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; | 16 | | revised 8-24-20.)
| 17 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 18 | | Sec. 5-5. Medical services. The Illinois Department, by | 19 | | rule, shall
determine the quantity and quality of and the rate | 20 | | of reimbursement for the
medical assistance for which
payment | 21 | | will be authorized, and the medical services to be provided,
| 22 | | which may include all or part of the following: (1) inpatient | 23 | | hospital
services; (2) outpatient hospital services; (3) other | 24 | | laboratory and
X-ray services; (4) skilled nursing home | 25 | | services; (5) physicians'
services whether furnished in the |
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| 1 | | office, the patient's home, a
hospital, a skilled nursing | 2 | | home, or elsewhere; (6) medical care, or any
other type of | 3 | | remedial care furnished by licensed practitioners; (7)
home | 4 | | health care services; (8) private duty nursing service; (9) | 5 | | clinic
services; (10) dental services, including prevention | 6 | | and treatment of periodontal disease and dental caries disease | 7 | | for pregnant individuals women , provided by an individual | 8 | | licensed to practice dentistry or dental surgery; for purposes | 9 | | of this item (10), "dental services" means diagnostic, | 10 | | preventive, or corrective procedures provided by or under the | 11 | | supervision of a dentist in the practice of his or her | 12 | | profession; (11) physical therapy and related
services; (12) | 13 | | prescribed drugs, dentures, and prosthetic devices; and
| 14 | | eyeglasses prescribed by a physician skilled in the diseases | 15 | | of the eye,
or by an optometrist, whichever the person may | 16 | | select; (13) other
diagnostic, screening, preventive, and | 17 | | rehabilitative services, including to ensure that the | 18 | | individual's need for intervention or treatment of mental | 19 | | disorders or substance use disorders or co-occurring mental | 20 | | health and substance use disorders is determined using a | 21 | | uniform screening, assessment, and evaluation process | 22 | | inclusive of criteria, for children and adults; for purposes | 23 | | of this item (13), a uniform screening, assessment, and | 24 | | evaluation process refers to a process that includes an | 25 | | appropriate evaluation and, as warranted, a referral; | 26 | | "uniform" does not mean the use of a singular instrument, |
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| 1 | | tool, or process that all must utilize; (14)
transportation | 2 | | and such other expenses as may be necessary; (15) medical
| 3 | | treatment of sexual assault survivors, as defined in
Section | 4 | | 1a of the Sexual Assault Survivors Emergency Treatment Act, | 5 | | for
injuries sustained as a result of the sexual assault, | 6 | | including
examinations and laboratory tests to discover | 7 | | evidence which may be used in
criminal proceedings arising | 8 | | from the sexual assault; (16) the
diagnosis and treatment of | 9 | | sickle cell anemia; and (17)
any other medical care, and any | 10 | | other type of remedial care recognized
under the laws of this | 11 | | State. The term "any other type of remedial care" shall
| 12 | | include nursing care and nursing home service for persons who | 13 | | rely on
treatment by spiritual means alone through prayer for | 14 | | healing.
| 15 | | Notwithstanding any other provision of this Section, a | 16 | | comprehensive
tobacco use cessation program that includes | 17 | | purchasing prescription drugs or
prescription medical devices | 18 | | approved by the Food and Drug Administration shall
be covered | 19 | | under the medical assistance
program under this Article for | 20 | | persons who are otherwise eligible for
assistance under this | 21 | | Article.
| 22 | | Notwithstanding any other provision of this Code, | 23 | | reproductive health care that is otherwise legal in Illinois | 24 | | shall be covered under the medical assistance program for | 25 | | persons who are otherwise eligible for medical assistance | 26 | | under this Article. |
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| 1 | | Notwithstanding any other provision of this Code, the | 2 | | Illinois
Department may not require, as a condition of payment | 3 | | for any laboratory
test authorized under this Article, that a | 4 | | physician's handwritten signature
appear on the laboratory | 5 | | test order form. The Illinois Department may,
however, impose | 6 | | other appropriate requirements regarding laboratory test
order | 7 | | documentation.
| 8 | | Upon receipt of federal approval of an amendment to the | 9 | | Illinois Title XIX State Plan for this purpose, the Department | 10 | | shall authorize the Chicago Public Schools (CPS) to procure a | 11 | | vendor or vendors to manufacture eyeglasses for individuals | 12 | | enrolled in a school within the CPS system. CPS shall ensure | 13 | | that its vendor or vendors are enrolled as providers in the | 14 | | medical assistance program and in any capitated Medicaid | 15 | | managed care entity (MCE) serving individuals enrolled in a | 16 | | school within the CPS system. Under any contract procured | 17 | | under this provision, the vendor or vendors must serve only | 18 | | individuals enrolled in a school within the CPS system. Claims | 19 | | for services provided by CPS's vendor or vendors to recipients | 20 | | of benefits in the medical assistance program under this Code, | 21 | | the Children's Health Insurance Program, or the Covering ALL | 22 | | KIDS Health Insurance Program shall be submitted to the | 23 | | Department or the MCE in which the individual is enrolled for | 24 | | payment and shall be reimbursed at the Department's or the | 25 | | MCE's established rates or rate methodologies for eyeglasses. | 26 | | On and after July 1, 2012, the Department of Healthcare |
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| 1 | | and Family Services may provide the following services to
| 2 | | persons
eligible for assistance under this Article who are | 3 | | participating in
education, training or employment programs | 4 | | operated by the Department of Human
Services as successor to | 5 | | the Department of Public Aid:
| 6 | | (1) dental services provided by or under the | 7 | | supervision of a dentist; and
| 8 | | (2) eyeglasses prescribed by a physician skilled in | 9 | | the diseases of the
eye, or by an optometrist, whichever | 10 | | the person may select.
| 11 | | On and after July 1, 2018, the Department of Healthcare | 12 | | and Family Services shall provide dental services to any adult | 13 | | who is otherwise eligible for assistance under the medical | 14 | | assistance program. As used in this paragraph, "dental | 15 | | services" means diagnostic, preventative, restorative, or | 16 | | corrective procedures, including procedures and services for | 17 | | the prevention and treatment of periodontal disease and dental | 18 | | caries disease, provided by an individual who is licensed to | 19 | | practice dentistry or dental surgery or who is under the | 20 | | supervision of a dentist in the practice of his or her | 21 | | profession. | 22 | | On and after July 1, 2018, targeted dental services, as | 23 | | set forth in Exhibit D of the Consent Decree entered by the | 24 | | United States District Court for the Northern District of | 25 | | Illinois, Eastern Division, in the matter of Memisovski v. | 26 | | Maram, Case No. 92 C 1982, that are provided to adults under |
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| 1 | | the medical assistance program shall be established at no less | 2 | | than the rates set forth in the "New Rate" column in Exhibit D | 3 | | of the Consent Decree for targeted dental services that are | 4 | | provided to persons under the age of 18 under the medical | 5 | | assistance program. | 6 | | Notwithstanding any other provision of this Code and | 7 | | subject to federal approval, the Department may adopt rules to | 8 | | allow a dentist who is volunteering his or her service at no | 9 | | cost to render dental services through an enrolled | 10 | | not-for-profit health clinic without the dentist personally | 11 | | enrolling as a participating provider in the medical | 12 | | assistance program. A not-for-profit health clinic shall | 13 | | include a public health clinic or Federally Qualified Health | 14 | | Center or other enrolled provider, as determined by the | 15 | | Department, through which dental services covered under this | 16 | | Section are performed. The Department shall establish a | 17 | | process for payment of claims for reimbursement for covered | 18 | | dental services rendered under this provision. | 19 | | The Illinois Department, by rule, may distinguish and | 20 | | classify the
medical services to be provided only in | 21 | | accordance with the classes of
persons designated in Section | 22 | | 5-2.
| 23 | | The Department of Healthcare and Family Services must | 24 | | provide coverage and reimbursement for amino acid-based | 25 | | elemental formulas, regardless of delivery method, for the | 26 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
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| 1 | | short bowel syndrome when the prescribing physician has issued | 2 | | a written order stating that the amino acid-based elemental | 3 | | formula is medically necessary.
| 4 | | The Illinois Department shall authorize the provision of, | 5 | | and shall
authorize payment for, screening by low-dose | 6 | | mammography for the presence of
occult breast cancer for | 7 | | individuals women 35 years of age or older who are eligible
for | 8 | | medical assistance under this Article, as follows: | 9 | | (A) A baseline
mammogram for individuals women 35 to | 10 | | 39 years of age.
| 11 | | (B) An annual mammogram for individuals women 40 years | 12 | | of age or older. | 13 | | (C) A mammogram at the age and intervals considered | 14 | | medically necessary by the individual's woman's health | 15 | | care provider for individuals women under 40 years of age | 16 | | and having a family history of breast cancer, prior | 17 | | personal history of breast cancer, positive genetic | 18 | | testing, or other risk factors. | 19 | | (D) A comprehensive ultrasound screening and MRI of an | 20 | | entire breast or breasts if a mammogram demonstrates | 21 | | heterogeneous or dense breast tissue or when medically | 22 | | necessary as determined by a physician licensed to | 23 | | practice medicine in all of its branches. | 24 | | (E) A screening MRI when medically necessary, as | 25 | | determined by a physician licensed to practice medicine in | 26 | | all of its branches. |
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| 1 | | (F) A diagnostic mammogram when medically necessary, | 2 | | as determined by a physician licensed to practice medicine | 3 | | in all its branches, advanced practice registered nurse, | 4 | | or physician assistant. | 5 | | The Department shall not impose a deductible, coinsurance, | 6 | | copayment, or any other cost-sharing requirement on the | 7 | | coverage provided under this paragraph; except that this | 8 | | sentence does not apply to coverage of diagnostic mammograms | 9 | | to the extent such coverage would disqualify a high-deductible | 10 | | health plan from eligibility for a health savings account | 11 | | pursuant to Section 223 of the Internal Revenue Code (26 | 12 | | U.S.C. 223). | 13 | | All screenings
shall
include a physical breast exam, | 14 | | instruction on self-examination and
information regarding the | 15 | | frequency of self-examination and its value as a
preventative | 16 | | tool. | 17 | | For purposes of this Section: | 18 | | "Diagnostic
mammogram" means a mammogram obtained using | 19 | | diagnostic mammography. | 20 | | "Diagnostic
mammography" means a method of screening that | 21 | | is designed to
evaluate an abnormality in a breast, including | 22 | | an abnormality seen
or suspected on a screening mammogram or a | 23 | | subjective or objective
abnormality otherwise detected in the | 24 | | breast. | 25 | | "Low-dose mammography" means
the x-ray examination of the | 26 | | breast using equipment dedicated specifically
for mammography, |
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| 1 | | including the x-ray tube, filter, compression device,
and | 2 | | image receptor, with an average radiation exposure delivery
of | 3 | | less than one rad per breast for 2 views of an average size | 4 | | breast.
The term also includes digital mammography and | 5 | | includes breast tomosynthesis. | 6 | | "Breast tomosynthesis" means a radiologic procedure that | 7 | | involves the acquisition of projection images over the | 8 | | stationary breast to produce cross-sectional digital | 9 | | three-dimensional images of the breast. | 10 | | If, at any time, the Secretary of the United States | 11 | | Department of Health and Human Services, or its successor | 12 | | agency, promulgates rules or regulations to be published in | 13 | | the Federal Register or publishes a comment in the Federal | 14 | | Register or issues an opinion, guidance, or other action that | 15 | | would require the State, pursuant to any provision of the | 16 | | Patient Protection and Affordable Care Act (Public Law | 17 | | 111-148), including, but not limited to, 42 U.S.C. | 18 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 19 | | of any coverage for breast tomosynthesis outlined in this | 20 | | paragraph, then the requirement that an insurer cover breast | 21 | | tomosynthesis is inoperative other than any such coverage | 22 | | authorized under Section 1902 of the Social Security Act, 42 | 23 | | U.S.C. 1396a, and the State shall not assume any obligation | 24 | | for the cost of coverage for breast tomosynthesis set forth in | 25 | | this paragraph.
| 26 | | On and after January 1, 2016, the Department shall ensure |
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| 1 | | that all networks of care for adult clients of the Department | 2 | | include access to at least one breast imaging Center of | 3 | | Imaging Excellence as certified by the American College of | 4 | | Radiology. | 5 | | On and after January 1, 2012, providers participating in a | 6 | | quality improvement program approved by the Department shall | 7 | | be reimbursed for screening and diagnostic mammography at the | 8 | | same rate as the Medicare program's rates, including the | 9 | | increased reimbursement for digital mammography. | 10 | | The Department shall convene an expert panel including | 11 | | representatives of hospitals, free-standing mammography | 12 | | facilities, and doctors, including radiologists, to establish | 13 | | quality standards for mammography. | 14 | | On and after January 1, 2017, providers participating in a | 15 | | breast cancer treatment quality improvement program approved | 16 | | by the Department shall be reimbursed for breast cancer | 17 | | treatment at a rate that is no lower than 95% of the Medicare | 18 | | program's rates for the data elements included in the breast | 19 | | cancer treatment quality program. | 20 | | The Department shall convene an expert panel, including | 21 | | representatives of hospitals, free-standing breast cancer | 22 | | treatment centers, breast cancer quality organizations, and | 23 | | doctors, including breast surgeons, reconstructive breast | 24 | | surgeons, oncologists, and primary care providers to establish | 25 | | quality standards for breast cancer treatment. | 26 | | Subject to federal approval, the Department shall |
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| 1 | | establish a rate methodology for mammography at federally | 2 | | qualified health centers and other encounter-rate clinics. | 3 | | These clinics or centers may also collaborate with other | 4 | | hospital-based mammography facilities. By January 1, 2016, the | 5 | | Department shall report to the General Assembly on the status | 6 | | of the provision set forth in this paragraph. | 7 | | The Department shall establish a methodology to remind | 8 | | individuals women who are age-appropriate for screening | 9 | | mammography, but who have not received a mammogram within the | 10 | | previous 18 months, of the importance and benefit of screening | 11 | | mammography. The Department shall work with experts in breast | 12 | | cancer outreach and patient navigation to optimize these | 13 | | reminders and shall establish a methodology for evaluating | 14 | | their effectiveness and modifying the methodology based on the | 15 | | evaluation. | 16 | | The Department shall establish a performance goal for | 17 | | primary care providers with respect to their female patients | 18 | | over age 40 receiving an annual mammogram. This performance | 19 | | goal shall be used to provide additional reimbursement in the | 20 | | form of a quality performance bonus to primary care providers | 21 | | who meet that goal. | 22 | | The Department shall devise a means of case-managing or | 23 | | patient navigation for beneficiaries diagnosed with breast | 24 | | cancer. This program shall initially operate as a pilot | 25 | | program in areas of the State with the highest incidence of | 26 | | mortality related to breast cancer. At least one pilot program |
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| 1 | | site shall be in the metropolitan Chicago area and at least one | 2 | | site shall be outside the metropolitan Chicago area. On or | 3 | | after July 1, 2016, the pilot program shall be expanded to | 4 | | include one site in western Illinois, one site in southern | 5 | | Illinois, one site in central Illinois, and 4 sites within | 6 | | metropolitan Chicago. An evaluation of the pilot program shall | 7 | | be carried out measuring health outcomes and cost of care for | 8 | | those served by the pilot program compared to similarly | 9 | | situated patients who are not served by the pilot program. | 10 | | The Department shall require all networks of care to | 11 | | develop a means either internally or by contract with experts | 12 | | in navigation and community outreach to navigate cancer | 13 | | patients to comprehensive care in a timely fashion. The | 14 | | Department shall require all networks of care to include | 15 | | access for patients diagnosed with cancer to at least one | 16 | | academic commission on cancer-accredited cancer program as an | 17 | | in-network covered benefit. | 18 | | On or after July 1, 2022, individuals who are otherwise | 19 | | eligible for medical assistance under this Article shall | 20 | | receive coverage for perinatal depression screenings for the | 21 | | 12-month period beginning on the last day of their pregnancy. | 22 | | Medical assistance coverage under this paragraph shall be | 23 | | conditioned on the use of a screening instrument approved by | 24 | | the Department. | 25 | | Any medical or health care provider shall immediately | 26 | | recommend, to
any pregnant individual woman who is being |
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| 1 | | provided prenatal services and is suspected
of having a | 2 | | substance use disorder as defined in the Substance Use | 3 | | Disorder Act, referral to a local substance use disorder | 4 | | treatment program licensed by the Department of Human Services | 5 | | or to a licensed
hospital which provides substance abuse | 6 | | treatment services. The Department of Healthcare and Family | 7 | | Services
shall assure coverage for the cost of treatment of | 8 | | the drug abuse or
addiction for pregnant recipients in | 9 | | accordance with the Illinois Medicaid
Program in conjunction | 10 | | with the Department of Human Services.
| 11 | | All medical providers providing medical assistance to | 12 | | pregnant individuals women
under this Code shall receive | 13 | | information from the Department on the
availability of | 14 | | services under any
program providing case management services | 15 | | for addicted individuals women ,
including information on | 16 | | appropriate referrals for other social services
that may be | 17 | | needed by addicted individuals women in addition to treatment | 18 | | for addiction.
| 19 | | The Illinois Department, in cooperation with the | 20 | | Departments of Human
Services (as successor to the Department | 21 | | of Alcoholism and Substance
Abuse) and Public Health, through | 22 | | a public awareness campaign, may
provide information | 23 | | concerning treatment for alcoholism and drug abuse and
| 24 | | addiction, prenatal health care, and other pertinent programs | 25 | | directed at
reducing the number of drug-affected infants born | 26 | | to recipients of medical
assistance.
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| 1 | | Neither the Department of Healthcare and Family Services | 2 | | nor the Department of Human
Services shall sanction the | 3 | | recipient solely on the basis of the recipient's
her substance | 4 | | abuse.
| 5 | | The Illinois Department shall establish such regulations | 6 | | governing
the dispensing of health services under this Article | 7 | | as it shall deem
appropriate. The Department
should
seek the | 8 | | advice of formal professional advisory committees appointed by
| 9 | | the Director of the Illinois Department for the purpose of | 10 | | providing regular
advice on policy and administrative matters, | 11 | | information dissemination and
educational activities for | 12 | | medical and health care providers, and
consistency in | 13 | | procedures to the Illinois Department.
| 14 | | The Illinois Department may develop and contract with | 15 | | Partnerships of
medical providers to arrange medical services | 16 | | for persons eligible under
Section 5-2 of this Code. | 17 | | Implementation of this Section may be by
demonstration | 18 | | projects in certain geographic areas. The Partnership shall
be | 19 | | represented by a sponsor organization. The Department, by | 20 | | rule, shall
develop qualifications for sponsors of | 21 | | Partnerships. Nothing in this
Section shall be construed to | 22 | | require that the sponsor organization be a
medical | 23 | | organization.
| 24 | | The sponsor must negotiate formal written contracts with | 25 | | medical
providers for physician services, inpatient and | 26 | | outpatient hospital care,
home health services, treatment for |
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| 1 | | alcoholism and substance abuse, and
other services determined | 2 | | necessary by the Illinois Department by rule for
delivery by | 3 | | Partnerships. Physician services must include prenatal and
| 4 | | obstetrical care. The Illinois Department shall reimburse | 5 | | medical services
delivered by Partnership providers to clients | 6 | | in target areas according to
provisions of this Article and | 7 | | the Illinois Health Finance Reform Act,
except that:
| 8 | | (1) Physicians participating in a Partnership and | 9 | | providing certain
services, which shall be determined by | 10 | | the Illinois Department, to persons
in areas covered by | 11 | | the Partnership may receive an additional surcharge
for | 12 | | such services.
| 13 | | (2) The Department may elect to consider and negotiate | 14 | | financial
incentives to encourage the development of | 15 | | Partnerships and the efficient
delivery of medical care.
| 16 | | (3) Persons receiving medical services through | 17 | | Partnerships may receive
medical and case management | 18 | | services above the level usually offered
through the | 19 | | medical assistance program.
| 20 | | Medical providers shall be required to meet certain | 21 | | qualifications to
participate in Partnerships to ensure the | 22 | | delivery of high quality medical
services. These | 23 | | qualifications shall be determined by rule of the Illinois
| 24 | | Department and may be higher than qualifications for | 25 | | participation in the
medical assistance program. Partnership | 26 | | sponsors may prescribe reasonable
additional qualifications |
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| 1 | | for participation by medical providers, only with
the prior | 2 | | written approval of the Illinois Department.
| 3 | | Nothing in this Section shall limit the free choice of | 4 | | practitioners,
hospitals, and other providers of medical | 5 | | services by clients.
In order to ensure patient freedom of | 6 | | choice, the Illinois Department shall
immediately promulgate | 7 | | all rules and take all other necessary actions so that
| 8 | | provided services may be accessed from therapeutically | 9 | | certified optometrists
to the full extent of the Illinois | 10 | | Optometric Practice Act of 1987 without
discriminating between | 11 | | service providers.
| 12 | | The Department shall apply for a waiver from the United | 13 | | States Health
Care Financing Administration to allow for the | 14 | | implementation of
Partnerships under this Section.
| 15 | | The Illinois Department shall require health care | 16 | | providers to maintain
records that document the medical care | 17 | | and services provided to recipients
of Medical Assistance | 18 | | under this Article. Such records must be retained for a period | 19 | | of not less than 6 years from the date of service or as | 20 | | provided by applicable State law, whichever period is longer, | 21 | | except that if an audit is initiated within the required | 22 | | retention period then the records must be retained until the | 23 | | audit is completed and every exception is resolved. The | 24 | | Illinois Department shall
require health care providers to | 25 | | make available, when authorized by the
patient, in writing, | 26 | | the medical records in a timely fashion to other
health care |
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| 1 | | providers who are treating or serving persons eligible for
| 2 | | Medical Assistance under this Article. All dispensers of | 3 | | medical services
shall be required to maintain and retain | 4 | | business and professional records
sufficient to fully and | 5 | | accurately document the nature, scope, details and
receipt of | 6 | | the health care provided to persons eligible for medical
| 7 | | assistance under this Code, in accordance with regulations | 8 | | promulgated by
the Illinois Department. The rules and | 9 | | regulations shall require that proof
of the receipt of | 10 | | prescription drugs, dentures, prosthetic devices and
| 11 | | eyeglasses by eligible persons under this Section accompany | 12 | | each claim
for reimbursement submitted by the dispenser of | 13 | | such medical services.
No such claims for reimbursement shall | 14 | | be approved for payment by the Illinois
Department without | 15 | | such proof of receipt, unless the Illinois Department
shall | 16 | | have put into effect and shall be operating a system of | 17 | | post-payment
audit and review which shall, on a sampling | 18 | | basis, be deemed adequate by
the Illinois Department to assure | 19 | | that such drugs, dentures, prosthetic
devices and eyeglasses | 20 | | for which payment is being made are actually being
received by | 21 | | eligible recipients. Within 90 days after September 16, 1984 | 22 | | (the effective date of Public Act 83-1439), the Illinois | 23 | | Department shall establish a
current list of acquisition costs | 24 | | for all prosthetic devices and any
other items recognized as | 25 | | medical equipment and supplies reimbursable under
this Article | 26 | | and shall update such list on a quarterly basis, except that
|
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| 1 | | the acquisition costs of all prescription drugs shall be | 2 | | updated no
less frequently than every 30 days as required by | 3 | | Section 5-5.12.
| 4 | | Notwithstanding any other law to the contrary, the | 5 | | Illinois Department shall, within 365 days after July 22, 2013 | 6 | | (the effective date of Public Act 98-104), establish | 7 | | procedures to permit skilled care facilities licensed under | 8 | | the Nursing Home Care Act to submit monthly billing claims for | 9 | | reimbursement purposes. Following development of these | 10 | | procedures, the Department shall, by July 1, 2016, test the | 11 | | viability of the new system and implement any necessary | 12 | | operational or structural changes to its information | 13 | | technology platforms in order to allow for the direct | 14 | | acceptance and payment of nursing home claims. | 15 | | Notwithstanding any other law to the contrary, the | 16 | | Illinois Department shall, within 365 days after August 15, | 17 | | 2014 (the effective date of Public Act 98-963), establish | 18 | | procedures to permit ID/DD facilities licensed under the ID/DD | 19 | | Community Care Act and MC/DD facilities licensed under the | 20 | | MC/DD Act to submit monthly billing claims for reimbursement | 21 | | purposes. Following development of these procedures, the | 22 | | Department shall have an additional 365 days to test the | 23 | | viability of the new system and to ensure that any necessary | 24 | | operational or structural changes to its information | 25 | | technology platforms are implemented. | 26 | | The Illinois Department shall require all dispensers of |
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| 1 | | medical
services, other than an individual practitioner or | 2 | | group of practitioners,
desiring to participate in the Medical | 3 | | Assistance program
established under this Article to disclose | 4 | | all financial, beneficial,
ownership, equity, surety or other | 5 | | interests in any and all firms,
corporations, partnerships, | 6 | | associations, business enterprises, joint
ventures, agencies, | 7 | | institutions or other legal entities providing any
form of | 8 | | health care services in this State under this Article.
| 9 | | The Illinois Department may require that all dispensers of | 10 | | medical
services desiring to participate in the medical | 11 | | assistance program
established under this Article disclose, | 12 | | under such terms and conditions as
the Illinois Department may | 13 | | by rule establish, all inquiries from clients
and attorneys | 14 | | regarding medical bills paid by the Illinois Department, which
| 15 | | inquiries could indicate potential existence of claims or | 16 | | liens for the
Illinois Department.
| 17 | | Enrollment of a vendor
shall be
subject to a provisional | 18 | | period and shall be conditional for one year. During the | 19 | | period of conditional enrollment, the Department may
terminate | 20 | | the vendor's eligibility to participate in, or may disenroll | 21 | | the vendor from, the medical assistance
program without cause. | 22 | | Unless otherwise specified, such termination of eligibility or | 23 | | disenrollment is not subject to the
Department's hearing | 24 | | process.
However, a disenrolled vendor may reapply without | 25 | | penalty.
| 26 | | The Department has the discretion to limit the conditional |
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| 1 | | enrollment period for vendors based upon category of risk of | 2 | | the vendor. | 3 | | Prior to enrollment and during the conditional enrollment | 4 | | period in the medical assistance program, all vendors shall be | 5 | | subject to enhanced oversight, screening, and review based on | 6 | | the risk of fraud, waste, and abuse that is posed by the | 7 | | category of risk of the vendor. The Illinois Department shall | 8 | | establish the procedures for oversight, screening, and review, | 9 | | which may include, but need not be limited to: criminal and | 10 | | financial background checks; fingerprinting; license, | 11 | | certification, and authorization verifications; unscheduled or | 12 | | unannounced site visits; database checks; prepayment audit | 13 | | reviews; audits; payment caps; payment suspensions; and other | 14 | | screening as required by federal or State law. | 15 | | The Department shall define or specify the following: (i) | 16 | | by provider notice, the "category of risk of the vendor" for | 17 | | each type of vendor, which shall take into account the level of | 18 | | screening applicable to a particular category of vendor under | 19 | | federal law and regulations; (ii) by rule or provider notice, | 20 | | the maximum length of the conditional enrollment period for | 21 | | each category of risk of the vendor; and (iii) by rule, the | 22 | | hearing rights, if any, afforded to a vendor in each category | 23 | | of risk of the vendor that is terminated or disenrolled during | 24 | | the conditional enrollment period. | 25 | | To be eligible for payment consideration, a vendor's | 26 | | payment claim or bill, either as an initial claim or as a |
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| 1 | | resubmitted claim following prior rejection, must be received | 2 | | by the Illinois Department, or its fiscal intermediary, no | 3 | | later than 180 days after the latest date on the claim on which | 4 | | medical goods or services were provided, with the following | 5 | | exceptions: | 6 | | (1) In the case of a provider whose enrollment is in | 7 | | process by the Illinois Department, the 180-day period | 8 | | shall not begin until the date on the written notice from | 9 | | the Illinois Department that the provider enrollment is | 10 | | complete. | 11 | | (2) In the case of errors attributable to the Illinois | 12 | | Department or any of its claims processing intermediaries | 13 | | which result in an inability to receive, process, or | 14 | | adjudicate a claim, the 180-day period shall not begin | 15 | | until the provider has been notified of the error. | 16 | | (3) In the case of a provider for whom the Illinois | 17 | | Department initiates the monthly billing process. | 18 | | (4) In the case of a provider operated by a unit of | 19 | | local government with a population exceeding 3,000,000 | 20 | | when local government funds finance federal participation | 21 | | for claims payments. | 22 | | For claims for services rendered during a period for which | 23 | | a recipient received retroactive eligibility, claims must be | 24 | | filed within 180 days after the Department determines the | 25 | | applicant is eligible. For claims for which the Illinois | 26 | | Department is not the primary payer, claims must be submitted |
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| 1 | | to the Illinois Department within 180 days after the final | 2 | | adjudication by the primary payer. | 3 | | In the case of long term care facilities, within 45 | 4 | | calendar days of receipt by the facility of required | 5 | | prescreening information, new admissions with associated | 6 | | admission documents shall be submitted through the Medical | 7 | | Electronic Data Interchange (MEDI) or the Recipient | 8 | | Eligibility Verification (REV) System or shall be submitted | 9 | | directly to the Department of Human Services using required | 10 | | admission forms. Effective September
1, 2014, admission | 11 | | documents, including all prescreening
information, must be | 12 | | submitted through MEDI or REV. Confirmation numbers assigned | 13 | | to an accepted transaction shall be retained by a facility to | 14 | | verify timely submittal. Once an admission transaction has | 15 | | been completed, all resubmitted claims following prior | 16 | | rejection are subject to receipt no later than 180 days after | 17 | | the admission transaction has been completed. | 18 | | Claims that are not submitted and received in compliance | 19 | | with the foregoing requirements shall not be eligible for | 20 | | payment under the medical assistance program, and the State | 21 | | shall have no liability for payment of those claims. | 22 | | To the extent consistent with applicable information and | 23 | | privacy, security, and disclosure laws, State and federal | 24 | | agencies and departments shall provide the Illinois Department | 25 | | access to confidential and other information and data | 26 | | necessary to perform eligibility and payment verifications and |
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| 1 | | other Illinois Department functions. This includes, but is not | 2 | | limited to: information pertaining to licensure; | 3 | | certification; earnings; immigration status; citizenship; wage | 4 | | reporting; unearned and earned income; pension income; | 5 | | employment; supplemental security income; social security | 6 | | numbers; National Provider Identifier (NPI) numbers; the | 7 | | National Practitioner Data Bank (NPDB); program and agency | 8 | | exclusions; taxpayer identification numbers; tax delinquency; | 9 | | corporate information; and death records. | 10 | | The Illinois Department shall enter into agreements with | 11 | | State agencies and departments, and is authorized to enter | 12 | | into agreements with federal agencies and departments, under | 13 | | which such agencies and departments shall share data necessary | 14 | | for medical assistance program integrity functions and | 15 | | oversight. The Illinois Department shall develop, in | 16 | | cooperation with other State departments and agencies, and in | 17 | | compliance with applicable federal laws and regulations, | 18 | | appropriate and effective methods to share such data. At a | 19 | | minimum, and to the extent necessary to provide data sharing, | 20 | | the Illinois Department shall enter into agreements with State | 21 | | agencies and departments, and is authorized to enter into | 22 | | agreements with federal agencies and departments, including , | 23 | | but not limited to: the Secretary of State; the Department of | 24 | | Revenue; the Department of Public Health; the Department of | 25 | | Human Services; and the Department of Financial and | 26 | | Professional Regulation. |
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| 1 | | Beginning in fiscal year 2013, the Illinois Department | 2 | | shall set forth a request for information to identify the | 3 | | benefits of a pre-payment, post-adjudication, and post-edit | 4 | | claims system with the goals of streamlining claims processing | 5 | | and provider reimbursement, reducing the number of pending or | 6 | | rejected claims, and helping to ensure a more transparent | 7 | | adjudication process through the utilization of: (i) provider | 8 | | data verification and provider screening technology; and (ii) | 9 | | clinical code editing; and (iii) pre-pay, pre- or | 10 | | post-adjudicated predictive modeling with an integrated case | 11 | | management system with link analysis. Such a request for | 12 | | information shall not be considered as a request for proposal | 13 | | or as an obligation on the part of the Illinois Department to | 14 | | take any action or acquire any products or services. | 15 | | The Illinois Department shall establish policies, | 16 | | procedures,
standards and criteria by rule for the | 17 | | acquisition, repair and replacement
of orthotic and prosthetic | 18 | | devices and durable medical equipment. Such
rules shall | 19 | | provide, but not be limited to, the following services: (1)
| 20 | | immediate repair or replacement of such devices by recipients; | 21 | | and (2) rental, lease, purchase or lease-purchase of
durable | 22 | | medical equipment in a cost-effective manner, taking into
| 23 | | consideration the recipient's medical prognosis, the extent of | 24 | | the
recipient's needs, and the requirements and costs for | 25 | | maintaining such
equipment. Subject to prior approval, such | 26 | | rules shall enable a recipient to temporarily acquire and
use |
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| 1 | | alternative or substitute devices or equipment pending repairs | 2 | | or
replacements of any device or equipment previously | 3 | | authorized for such
recipient by the Department. | 4 | | Notwithstanding any provision of Section 5-5f to the contrary, | 5 | | the Department may, by rule, exempt certain replacement | 6 | | wheelchair parts from prior approval and, for wheelchairs, | 7 | | wheelchair parts, wheelchair accessories, and related seating | 8 | | and positioning items, determine the wholesale price by | 9 | | methods other than actual acquisition costs. | 10 | | The Department shall require, by rule, all providers of | 11 | | durable medical equipment to be accredited by an accreditation | 12 | | organization approved by the federal Centers for Medicare and | 13 | | Medicaid Services and recognized by the Department in order to | 14 | | bill the Department for providing durable medical equipment to | 15 | | recipients. No later than 15 months after the effective date | 16 | | of the rule adopted pursuant to this paragraph, all providers | 17 | | must meet the accreditation requirement.
| 18 | | In order to promote environmental responsibility, meet the | 19 | | needs of recipients and enrollees, and achieve significant | 20 | | cost savings, the Department, or a managed care organization | 21 | | under contract with the Department, may provide recipients or | 22 | | managed care enrollees who have a prescription or Certificate | 23 | | of Medical Necessity access to refurbished durable medical | 24 | | equipment under this Section (excluding prosthetic and | 25 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 26 | | Pedorthics Practice Act and complex rehabilitation technology |
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| 1 | | products and associated services) through the State's | 2 | | assistive technology program's reutilization program, using | 3 | | staff with the Assistive Technology Professional (ATP) | 4 | | Certification if the refurbished durable medical equipment: | 5 | | (i) is available; (ii) is less expensive, including shipping | 6 | | costs, than new durable medical equipment of the same type; | 7 | | (iii) is able to withstand at least 3 years of use; (iv) is | 8 | | cleaned, disinfected, sterilized, and safe in accordance with | 9 | | federal Food and Drug Administration regulations and guidance | 10 | | governing the reprocessing of medical devices in health care | 11 | | settings; and (v) equally meets the needs of the recipient or | 12 | | enrollee. The reutilization program shall confirm that the | 13 | | recipient or enrollee is not already in receipt of same or | 14 | | similar equipment from another service provider, and that the | 15 | | refurbished durable medical equipment equally meets the needs | 16 | | of the recipient or enrollee. Nothing in this paragraph shall | 17 | | be construed to limit recipient or enrollee choice to obtain | 18 | | new durable medical equipment or place any additional prior | 19 | | authorization conditions on enrollees of managed care | 20 | | organizations. | 21 | | The Department shall execute, relative to the nursing home | 22 | | prescreening
project, written inter-agency agreements with the | 23 | | Department of Human
Services and the Department on Aging, to | 24 | | effect the following: (i) intake
procedures and common | 25 | | eligibility criteria for those persons who are receiving
| 26 | | non-institutional services; and (ii) the establishment and |
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| 1 | | development of
non-institutional services in areas of the | 2 | | State where they are not currently
available or are | 3 | | undeveloped; and (iii) notwithstanding any other provision of | 4 | | law, subject to federal approval, on and after July 1, 2012, an | 5 | | increase in the determination of need (DON) scores from 29 to | 6 | | 37 for applicants for institutional and home and | 7 | | community-based long term care; if and only if federal | 8 | | approval is not granted, the Department may, in conjunction | 9 | | with other affected agencies, implement utilization controls | 10 | | or changes in benefit packages to effectuate a similar savings | 11 | | amount for this population; and (iv) no later than July 1, | 12 | | 2013, minimum level of care eligibility criteria for | 13 | | institutional and home and community-based long term care; and | 14 | | (v) no later than October 1, 2013, establish procedures to | 15 | | permit long term care providers access to eligibility scores | 16 | | for individuals with an admission date who are seeking or | 17 | | receiving services from the long term care provider. In order | 18 | | to select the minimum level of care eligibility criteria, the | 19 | | Governor shall establish a workgroup that includes affected | 20 | | agency representatives and stakeholders representing the | 21 | | institutional and home and community-based long term care | 22 | | interests. This Section shall not restrict the Department from | 23 | | implementing lower level of care eligibility criteria for | 24 | | community-based services in circumstances where federal | 25 | | approval has been granted.
| 26 | | The Illinois Department shall develop and operate, in |
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| 1 | | cooperation
with other State Departments and agencies and in | 2 | | compliance with
applicable federal laws and regulations, | 3 | | appropriate and effective
systems of health care evaluation | 4 | | and programs for monitoring of
utilization of health care | 5 | | services and facilities, as it affects
persons eligible for | 6 | | medical assistance under this Code.
| 7 | | The Illinois Department shall report annually to the | 8 | | General Assembly,
no later than the second Friday in April of | 9 | | 1979 and each year
thereafter, in regard to:
| 10 | | (a) actual statistics and trends in utilization of | 11 | | medical services by
public aid recipients;
| 12 | | (b) actual statistics and trends in the provision of | 13 | | the various medical
services by medical vendors;
| 14 | | (c) current rate structures and proposed changes in | 15 | | those rate structures
for the various medical vendors; and
| 16 | | (d) efforts at utilization review and control by the | 17 | | Illinois Department.
| 18 | | The period covered by each report shall be the 3 years | 19 | | ending on the June
30 prior to the report. The report shall | 20 | | include suggested legislation
for consideration by the General | 21 | | Assembly. The requirement for reporting to the General | 22 | | Assembly shall be satisfied
by filing copies of the report as | 23 | | required by Section 3.1 of the General Assembly Organization | 24 | | Act, and filing such additional
copies
with the State | 25 | | Government Report Distribution Center for the General
Assembly | 26 | | as is required under paragraph (t) of Section 7 of the State
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| 1 | | Library Act.
| 2 | | Rulemaking authority to implement Public Act 95-1045, if | 3 | | any, is conditioned on the rules being adopted in accordance | 4 | | with all provisions of the Illinois Administrative Procedure | 5 | | Act and all rules and procedures of the Joint Committee on | 6 | | Administrative Rules; any purported rule not so adopted, for | 7 | | whatever reason, is unauthorized. | 8 | | On and after July 1, 2012, the Department shall reduce any | 9 | | rate of reimbursement for services or other payments or alter | 10 | | any methodologies authorized by this Code to reduce any rate | 11 | | of reimbursement for services or other payments in accordance | 12 | | with Section 5-5e. | 13 | | Because kidney transplantation can be an appropriate, | 14 | | cost-effective
alternative to renal dialysis when medically | 15 | | necessary and notwithstanding the provisions of Section 1-11 | 16 | | of this Code, beginning October 1, 2014, the Department shall | 17 | | cover kidney transplantation for noncitizens with end-stage | 18 | | renal disease who are not eligible for comprehensive medical | 19 | | benefits, who meet the residency requirements of Section 5-3 | 20 | | of this Code, and who would otherwise meet the financial | 21 | | requirements of the appropriate class of eligible persons | 22 | | under Section 5-2 of this Code. To qualify for coverage of | 23 | | kidney transplantation, such person must be receiving | 24 | | emergency renal dialysis services covered by the Department. | 25 | | Providers under this Section shall be prior approved and | 26 | | certified by the Department to perform kidney transplantation |
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| 1 | | and the services under this Section shall be limited to | 2 | | services associated with kidney transplantation. | 3 | | Notwithstanding any other provision of this Code to the | 4 | | contrary, on or after July 1, 2015, all FDA approved forms of | 5 | | medication assisted treatment prescribed for the treatment of | 6 | | alcohol dependence or treatment of opioid dependence shall be | 7 | | covered under both fee for service and managed care medical | 8 | | assistance programs for persons who are otherwise eligible for | 9 | | medical assistance under this Article and shall not be subject | 10 | | to any (1) utilization control, other than those established | 11 | | under the American Society of Addiction Medicine patient | 12 | | placement criteria,
(2) prior authorization mandate, or (3) | 13 | | lifetime restriction limit
mandate. | 14 | | On or after July 1, 2015, opioid antagonists prescribed | 15 | | for the treatment of an opioid overdose, including the | 16 | | medication product, administration devices, and any pharmacy | 17 | | fees related to the dispensing and administration of the | 18 | | opioid antagonist, shall be covered under the medical | 19 | | assistance program for persons who are otherwise eligible for | 20 | | medical assistance under this Article. As used in this | 21 | | Section, "opioid antagonist" means a drug that binds to opioid | 22 | | receptors and blocks or inhibits the effect of opioids acting | 23 | | on those receptors, including, but not limited to, naloxone | 24 | | hydrochloride or any other similarly acting drug approved by | 25 | | the U.S. Food and Drug Administration. | 26 | | Upon federal approval, the Department shall provide |
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| 1 | | coverage and reimbursement for all drugs that are approved for | 2 | | marketing by the federal Food and Drug Administration and that | 3 | | are recommended by the federal Public Health Service or the | 4 | | United States Centers for Disease Control and Prevention for | 5 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 6 | | services, including, but not limited to, HIV and sexually | 7 | | transmitted infection screening, treatment for sexually | 8 | | transmitted infections, medical monitoring, assorted labs, and | 9 | | counseling to reduce the likelihood of HIV infection among | 10 | | individuals who are not infected with HIV but who are at high | 11 | | risk of HIV infection. | 12 | | A federally qualified health center, as defined in Section | 13 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 14 | | reimbursed by the Department in accordance with the federally | 15 | | qualified health center's encounter rate for services provided | 16 | | to medical assistance recipients that are performed by a | 17 | | dental hygienist, as defined under the Illinois Dental | 18 | | Practice Act, working under the general supervision of a | 19 | | dentist and employed by a federally qualified health center. | 20 | | Within 90 days after the effective date of this amendatory | 21 | | Act of the 102nd General Assembly, the Department shall seek | 22 | | federal approval of a State Plan amendment to expand coverage | 23 | | for family planning services that includes presumptive | 24 | | eligibility to individuals whose income is at or below 208% of | 25 | | the federal poverty level. Coverage under this Section shall | 26 | | be effective beginning on July 1, 2022. |
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| 1 | | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | 2 | | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | 3 | | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | 4 | | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | 5 | | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | 6 | | 1-1-20; revised 9-18-19.)
| 7 | | (305 ILCS 5/5-5.24)
| 8 | | Sec. 5-5.24. Prenatal and perinatal care. The Department | 9 | | of
Healthcare and Family Services may provide reimbursement | 10 | | under this Article for all prenatal and
perinatal health care | 11 | | services that are provided for the purpose of preventing
| 12 | | low-birthweight infants, reducing the need for neonatal | 13 | | intensive care hospital
services, and promoting perinatal and | 14 | | maternal health. These services may include
comprehensive risk | 15 | | assessments for pregnant individuals women , individuals women | 16 | | with infants, and
infants, lactation counseling, nutrition | 17 | | counseling, childbirth support,
psychosocial counseling, | 18 | | treatment and prevention of periodontal disease, language | 19 | | translation, nurse home visitation, and
other support
services
| 20 | | that have been proven to improve birth and maternal health | 21 | | outcomes.
The Department
shall
maximize the use of preventive | 22 | | prenatal and perinatal health care services
consistent with
| 23 | | federal statutes, rules, and regulations.
The Department of | 24 | | Public Aid (now Department of Healthcare and Family Services)
| 25 | | shall develop a plan for prenatal and perinatal preventive
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| 1 | | health care and
shall present the plan to the General Assembly | 2 | | by January 1, 2004.
On or before January 1, 2006 and
every 2 | 3 | | years
thereafter, the Department shall report to the General | 4 | | Assembly concerning the
effectiveness of prenatal and | 5 | | perinatal health care services reimbursed under
this Section
| 6 | | in preventing low-birthweight infants and reducing the need | 7 | | for neonatal
intensive care
hospital services. Each such | 8 | | report shall include an evaluation of how the
ratio of
| 9 | | expenditures for treating
low-birthweight infants compared | 10 | | with the investment in promoting healthy
births and
infants in | 11 | | local community areas throughout Illinois relates to healthy | 12 | | infant
development
in those areas.
| 13 | | On and after July 1, 2012, the Department shall reduce any | 14 | | rate of reimbursement for services or other payments or alter | 15 | | any methodologies authorized by this Code to reduce any rate | 16 | | of reimbursement for services or other payments in accordance | 17 | | with Section 5-5e. | 18 | | (Source: P.A. 97-689, eff. 6-14-12.)
| 19 | | (305 ILCS 5/5-18.10 new) | 20 | | Sec. 5-18.10. Reimbursement for postpartum visits. | 21 | | (a) In this Section: | 22 | | "Certified lactation counselor" means a health care | 23 | | professional in lactation counseling who has demonstrated the | 24 | | necessary skills, knowledge, and attitudes to provide clinical | 25 | | breastfeeding counseling and management support to families |
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| 1 | | who are thinking about breastfeeding or who have questions or | 2 | | problems during the course of breastfeeding. | 3 | | "Certified nurse midwife" means a person who exceeds the | 4 | | competencies for a midwife contained in the Essential | 5 | | Competencies for Midwifery Practice, published by the | 6 | | International Confederation of Midwives, and who qualifies as | 7 | | an advanced practice registered nurse. | 8 | | "Community health worker" means a frontline public health | 9 | | worker who is a trusted member or has an unusually close | 10 | | understanding of the community served. This trusting | 11 | | relationship enables the community health worker to serve as a | 12 | | liaison, link, and intermediary between health and social | 13 | | services and the community to facilitate access to services | 14 | | and improve the quality and cultural competence of service | 15 | | delivery. | 16 | | "International board-certified lactation consultant" | 17 | | means a health care professional who is certified by the | 18 | | International Board of Lactation Consultant Examiners and | 19 | | specializes in the clinical management of breastfeeding. | 20 | | "Medical caseworker" means a health care professional who | 21 | | assists in the planning, coordination, monitoring, and | 22 | | evaluation of medical services for a patient with emphasis on | 23 | | quality of care, continuity of services, and affordability. | 24 | | "Perinatal doula" means a trained provider of regular and | 25 | | voluntary physical, emotional, and educational support, but | 26 | | not medical or midwife care, to pregnant and birthing persons |
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| 1 | | before, during, and after childbirth, otherwise known as the | 2 | | perinatal period. | 3 | | "Public health nurse" means a registered nurse who | 4 | | promotes and protects the health of populations using | 5 | | knowledge from nursing, social, and public health sciences. | 6 | | (b) The Illinois Department shall establish a medical | 7 | | assistance program to cover a universal postpartum visit | 8 | | within the first 3 weeks after childbirth and a comprehensive | 9 | | visit within 4 to 12 weeks postpartum for persons who are | 10 | | otherwise eligible for medical assistance under this Article. | 11 | | In addition, postpartum care services rendered by perinatal | 12 | | doulas, certified lactation counselors, international | 13 | | board-certified lactation consultants, public health nurses, | 14 | | certified nurse midwives, community health workers, and | 15 | | medical caseworkers shall be covered under the medical | 16 | | assistance program. | 17 | | Section 99. Effective date. This Act takes effect upon | 18 | | becoming law. |
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