Illinois General Assembly - Full Text of SB0967
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Full Text of SB0967  102nd General Assembly

SB0967enr 102ND GENERAL ASSEMBLY



 


 
SB0967 EnrolledLRB102 04880 CPF 14899 b

1    AN ACT concerning health.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. This Act may be referred to as the Improving
5Health Care for Pregnant and Postpartum Individuals Act.
 
6    Section 5. The State Employees Group Insurance Act of 1971
7is amended by changing Section 6.11 as follows:
 
8    (5 ILCS 375/6.11)
9    Sec. 6.11. Required health benefits; Illinois Insurance
10Code requirements. The program of health benefits shall
11provide the post-mastectomy care benefits required to be
12covered by a policy of accident and health insurance under
13Section 356t of the Illinois Insurance Code. The program of
14health benefits shall provide the coverage required under
15Sections 356g, 356g.5, 356g.5-1, 356m, 356u, 356w, 356x,
16356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
17356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
18356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
19356z.36, 356z.40, and 356z.41 of the Illinois Insurance Code.
20The program of health benefits must comply with Sections
21155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article
22XXXIIB of the Illinois Insurance Code. The Department of

 

 

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1Insurance shall enforce the requirements of this Section with
2respect to Sections 370c and 370c.1 of the Illinois Insurance
3Code; all other requirements of this Section shall be enforced
4by the Department of Central Management Services.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
12100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
131-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13,
14eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
15101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
161-1-21.)
 
17    Section 10. The Department of Human Services Act is
18amended by adding Section 10-23 as follows:
 
19    (20 ILCS 1305/10-23 new)
20    Sec. 10-23. High-risk pregnant or postpartum individuals.
21The Department shall expand and update its maternal child
22health programs to serve pregnant and postpartum individuals
23determined to be high-risk using criteria established by a
24multi-agency working group. The services shall be provided by

 

 

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1registered nurses, licensed social workers, or other staff
2with behavioral health or medical training, as approved by the
3Department. The persons providing the services may collaborate
4with other providers, including, but not limited to,
5obstetricians, gynecologists, or pediatricians, when providing
6services to a patient.
 
7    Section 15. The Department of Public Health Powers and
8Duties Law of the Civil Administrative Code of Illinois is
9amended by renumbering and changing Section 2310-223, as added
10by Public Act 101-390, and by adding Section 2310-470 as
11follows:
 
12    (20 ILCS 2310/2310-222)
13    Sec. 2310-222 2310-223. Obstetric hemorrhage and
14hypertension training.
15    (a) As used in this Section: ,
16    "Birthing birthing facility" means (1) a hospital, as
17defined in the Hospital Licensing Act, with more than one
18licensed obstetric bed or a neonatal intensive care unit; (2)
19a hospital operated by a State university; or (3) a birth
20center, as defined in the Alternative Health Care Delivery
21Act.
22    "Postpartum" means the 12-month period after a person has
23delivered a baby.
24    (b) The Department shall ensure that all birthing

 

 

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1facilities have a written policy and conduct continuing
2education yearly for providers and staff of obstetric medicine
3and of the emergency department and other staff that may care
4for pregnant or postpartum women. The written policy and
5continuing education shall include yearly educational modules
6regarding management of severe maternal hypertension and
7obstetric hemorrhage and other leading causes of maternal
8mortality for units that care for pregnant or postpartum
9women. Birthing facilities must demonstrate compliance with
10these written policy, education, and training requirements.
11    (c) The Department shall collaborate with the Illinois
12Perinatal Quality Collaborative or its successor organization
13to develop an initiative to improve birth equity and reduce
14peripartum racial and ethnic disparities. The Department shall
15ensure that the initiative includes the development of best
16practices for implicit bias training and education in cultural
17competency to be used by birthing facilities in interactions
18between patients and providers. In developing the initiative,
19the Illinois Perinatal Quality Collaborative or its successor
20organization shall consider existing programs, such as the
21Alliance for Innovation on Maternal Health and the California
22Maternal Quality Collaborative's pilot work on improving birth
23equity. The Department shall support the initiation of a
24statewide perinatal quality improvement initiative in
25collaboration with birthing facilities to implement strategies
26to reduce peripartum racial and ethnic disparities and to

 

 

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1address implicit bias in the health care system.
2    (d) In order to better facilitate continuity of care, the
3The Department, in consultation with the Illinois Perinatal
4Quality Collaborative Maternal Mortality Review Committee,
5shall make available to all birthing facilities best practices
6for timely identification and assessment of all pregnant and
7postpartum women for common pregnancy or postpartum
8complications in the emergency department and for care
9provided by the birthing facility throughout the pregnancy and
10postpartum period. The best practices shall include the
11appropriate and timely consultation of an obstetric or other
12relevant provider to provide input on management and
13follow-up, such as offering coordination of a post-delivery
14early postpartum visit or other services that may be
15appropriate and available. Birthing facilities shall
16incorporate these best practices into the written policy
17required under subsection (b). Birthing facilities may use
18telemedicine for the consultation.
19    (e) The Department may adopt rules for the purpose of
20implementing 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,
24in collaboration with the Department of Human Services, the
25Department of Healthcare and Family Services, and other key

 

 

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1providers of maternal child health services, shall revise or
2add to the rules of the Maternal and Child Health Services Code
3(77 Ill. Adm. Code 630) that govern the High Risk Infant
4Follow-up, using current scientific and national and State
5outcomes data, to revise or expand existing services to
6improve both maternal and infant outcomes overall and to
7reduce racial disparities in outcomes and services provided.
8The rules shall be revised or adopted on or before June 1,
92024.
 
10    Section 20. The Counties Code is amended by changing
11Section 5-1069.3 as follows:
 
12    (55 ILCS 5/5-1069.3)
13    Sec. 5-1069.3. Required health benefits. If a county,
14including a home rule county, is a self-insurer for purposes
15of providing health insurance coverage for its employees, the
16coverage shall include coverage for the post-mastectomy care
17benefits required to be covered by a policy of accident and
18health insurance under Section 356t and the coverage required
19under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
20356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
21356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
22356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
23the Illinois Insurance Code. The coverage shall comply with
24Sections 155.22a, 355b, 356z.19, and 370c of the Illinois

 

 

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1Insurance Code. The Department of Insurance shall enforce the
2requirements of this Section. The requirement that health
3benefits be covered as provided in this Section is an
4exclusive power and function of the State and is a denial and
5limitation under Article VII, Section 6, subsection (h) of the
6Illinois Constitution. A home rule county to which this
7Section applies must comply with every provision of this
8Section.
9    Rulemaking authority to implement Public Act 95-1045, if
10any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
16100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
171-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
18eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
19101-625, eff. 1-1-21.)
 
20    Section 25. The Illinois Municipal Code is amended by
21changing 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
24municipality, including a home rule municipality, is a

 

 

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1self-insurer for purposes of providing health insurance
2coverage for its employees, the coverage shall include
3coverage for the post-mastectomy care benefits required to be
4covered by a policy of accident and health insurance under
5Section 356t and the coverage required under Sections 356g,
6356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9,
7356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
8356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
9356z.36, 356z.40, and 356z.41 of the Illinois Insurance Code.
10The coverage shall comply with Sections 155.22a, 355b,
11356z.19, and 370c of the Illinois Insurance Code. The
12Department of Insurance shall enforce the requirements of this
13Section. The requirement that health benefits be covered as
14provided in this is an exclusive power and function of the
15State and is a denial and limitation under Article VII,
16Section 6, subsection (h) of the Illinois Constitution. A home
17rule municipality to which this Section applies must comply
18with every provision of this Section.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
26100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.

 

 

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11-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
2eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
3101-625, eff. 1-1-21.)
 
4    Section 30. The School Code is amended by changing Section
510-22.3f as follows:
 
6    (105 ILCS 5/10-22.3f)
7    Sec. 10-22.3f. Required health benefits. Insurance
8protection and benefits for employees shall provide the
9post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t and
11the coverage required under Sections 356g, 356g.5, 356g.5-1,
12356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
13356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
14356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
15the Illinois Insurance Code. Insurance policies shall comply
16with Section 356z.19 of the Illinois Insurance Code. The
17coverage shall comply with Sections 155.22a, 355b, and 370c of
18the Illinois Insurance Code. The Department of Insurance shall
19enforce the requirements of this Section.
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
3100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
41-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
5eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
6101-625, eff. 1-1-21.)
 
7    Section 35. The Illinois Insurance Code is amended by
8adding Sections 356z.4b and 356z.40 as follows:
 
9    (215 ILCS 5/356z.4b new)
10    Sec. 356z.4b. Billing for long-acting reversible
11contraceptives.
12    (a) In this Section, "long-acting reversible contraceptive
13device" means any intrauterine device or contraceptive
14implant.
15    (b) Any individual or group policy of accident and health
16insurance or qualified health plan that is offered through the
17health insurance marketplace that is amended, delivered,
18issued, or renewed on or after the effective date of this
19amendatory Act of the 102nd General Assembly shall allow
20hospitals separate reimbursement for a long-acting reversible
21contraceptive device provided immediately postpartum in the
22inpatient hospital setting before hospital discharge. The
23payment shall be made in addition to a bundled or Diagnostic
24Related 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
4insurance or managed care plan amended, delivered, issued, or
5renewed on or after the effective date of this amendatory Act
6of the 102nd General Assembly shall provide coverage for
7pregnancy and newborn care in accordance with 42 U.S.C.
818022(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
4amended 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
8the provisions of Sections 133, 134, 136, 137, 139, 140,
9141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
10154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
11355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
12356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
13356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
14356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
15356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.40,
16356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
17368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
18408.2, 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,
20XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois
21Insurance Code.
22    (b) For purposes of the Illinois Insurance Code, except
23for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
24Health Maintenance Organizations in the following categories

 

 

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1are 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
13acquisition of control of a Health Maintenance Organization
14pursuant 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
20Insurance Code and this Section 5-3 shall apply to the sale by
21any health maintenance organization of greater than 10% of its
22enrollee population (including without limitation the health
23maintenance organization's right, title, and interest in and
24to its health care certificates).
25    (e) In considering any management contract or service
26agreement subject to Section 141.1 of the Illinois Insurance

 

 

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1Code, the Director (i) shall, in addition to the criteria
2specified in Section 141.2 of the Illinois Insurance Code,
3take into account the effect of the management contract or
4service agreement on the continuation of benefits to enrollees
5and the financial condition of the health maintenance
6organization to be managed or serviced, and (ii) need not take
7into account the effect of the management contract or service
8agreement on competition.
9    (f) Except for small employer groups as defined in the
10Small Employer Rating, Renewability and Portability Health
11Insurance Act and except for medicare supplement policies as
12defined in Section 363 of the Illinois Insurance Code, a
13Health Maintenance Organization may by contract agree with a
14group or other enrollment unit to effect refunds or charge
15additional 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

 

 

SB0967 Enrolled- 20 -LRB102 04880 CPF 14899 b

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
12statement in the evidence of coverage issued to each enrollee
13describing the possibility of a refund or additional premium,
14and upon request of any group or enrollment unit, provide to
15the group or enrollment unit a description of the method used
16to calculate (1) the Health Maintenance Organization's
17profitable experience with respect to the group or enrollment
18unit and the resulting refund to the group or enrollment unit
19or (2) the Health Maintenance Organization's unprofitable
20experience with respect to the group or enrollment unit and
21the resulting additional premium to be paid by the group or
22enrollment unit.
23    In no event shall the Illinois Health Maintenance
24Organization Guaranty Association be liable to pay any
25contractual obligation of an insolvent organization to pay any
26refund authorized under this Section.

 

 

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1    (g) Rulemaking authority to implement Public Act 95-1045,
2if any, is conditioned on the rules being adopted in
3accordance with all provisions of the Illinois Administrative
4Procedure Act and all rules and procedures of the Joint
5Committee on Administrative Rules; any purported rule not so
6adopted, for whatever reason, is unauthorized.
7(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
8100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
91-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
10eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;
11101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
121-1-20; 101-625, eff. 1-1-21.)
 
13    Section 45. The Voluntary Health Services Plans Act is
14amended 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
17services plan corporations and all persons interested therein
18or dealing therewith shall be subject to the provisions of
19Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
20143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
21356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x,
22356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
23356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
24356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29,

 

 

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1356z.30, 356z.30a, 356z.32, 356z.33, 356z.40, 356z.41, 364.01,
2367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
3and paragraphs (7) and (15) of Section 367 of the Illinois
4Insurance Code.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
12100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
131-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
14eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
15101-625, eff. 1-1-21.)
 
16    Section 50. The Illinois Public Aid Code is amended by
17changing Sections 5-2, 5-5, and 5-5.24 and by adding Section
185-18.10 as follows:
 
19    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
20    Sec. 5-2. Classes of persons eligible. Medical assistance
21under this Article shall be available to any of the following
22classes of persons in respect to whom a plan for coverage has
23been submitted to the Governor by the Illinois Department and
24approved by him. If changes made in this Section 5-2 require

 

 

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1federal approval, they shall not take effect until such
2approval 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

 

 

SB0967 Enrolled- 26 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 27 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 28 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 29 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 30 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 31 -LRB102 04880 CPF 14899 b

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.

 

 

SB0967 Enrolled- 32 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 33 -LRB102 04880 CPF 14899 b

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.

 

 

SB0967 Enrolled- 34 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 35 -LRB102 04880 CPF 14899 b

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

 

 

SB0967 Enrolled- 36 -LRB102 04880 CPF 14899 b

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
24Department is authorized to adopt only those rules necessary,
25including emergency rules. Nothing in Public Act 96-20 permits
26the Department to adopt rules or issue a decision that expands

 

 

SB0967 Enrolled- 37 -LRB102 04880 CPF 14899 b

1eligibility for the FamilyCare Program to a person whose
2income exceeds 185% of the Federal Poverty Level as determined
3from time to time by the U.S. Department of Health and Human
4Services, unless the Department is provided with express
5statutory authority.
6    The eligibility of any such person for medical assistance
7under this Article is not affected by the payment of any grant
8under the Senior Citizens and Persons with Disabilities
9Property Tax Relief Act or any distributions or items of
10income described under subparagraph (X) of paragraph (2) of
11subsection (a) of Section 203 of the Illinois Income Tax Act.
12    The Department shall by rule establish the amounts of
13assets to be disregarded in determining eligibility for
14medical assistance, which shall at a minimum equal the amounts
15to be disregarded under the Federal Supplemental Security
16Income Program. The amount of assets of a single person to be
17disregarded shall not be less than $2,000, and the amount of
18assets of a married couple to be disregarded shall not be less
19than $3,000.
20    To the extent permitted under federal law, any person
21found guilty of a second violation of Article VIIIA shall be
22ineligible for medical assistance under this Article, as
23provided in Section 8A-8.
24    The eligibility of any person for medical assistance under
25this Article shall not be affected by the receipt by the person
26of donations or benefits from fundraisers held for the person

 

 

SB0967 Enrolled- 38 -LRB102 04880 CPF 14899 b

1in cases of serious illness, as long as neither the person nor
2members of the person's family have actual control over the
3donations or benefits or the disbursement of the donations or
4benefits.
5    Notwithstanding any other provision of this Code, if the
6United States Supreme Court holds Title II, Subtitle A,
7Section 2001(a) of Public Law 111-148 to be unconstitutional,
8or if a holding of Public Law 111-148 makes Medicaid
9eligibility allowed under Section 2001(a) inoperable, the
10State or a unit of local government shall be prohibited from
11enrolling individuals in the Medical Assistance Program as the
12result of federal approval of a State Medicaid waiver on or
13after June 14, 2012 (the effective date of Public Act 97-687)
14this amendatory Act of the 97th General Assembly, and any
15individuals enrolled in the Medical Assistance Program
16pursuant to eligibility permitted as a result of such a State
17Medicaid waiver shall become immediately ineligible.
18    Notwithstanding any other provision of this Code, if an
19Act of Congress that becomes a Public Law eliminates Section
202001(a) of Public Law 111-148, the State or a unit of local
21government shall be prohibited from enrolling individuals in
22the Medical Assistance Program as the result of federal
23approval of a State Medicaid waiver on or after June 14, 2012
24(the effective date of Public Act 97-687) this amendatory Act
25of the 97th General Assembly, and any individuals enrolled in
26the Medical Assistance Program pursuant to eligibility

 

 

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1permitted as a result of such a State Medicaid waiver shall
2become immediately ineligible.
3    Effective October 1, 2013, the determination of
4eligibility of persons who qualify under paragraphs 5, 6, 8,
515, 17, and 18 of this Section shall comply with the
6requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
7regulations.
8    The Department of Healthcare and Family Services, the
9Department of Human Services, and the Illinois health
10insurance marketplace shall work cooperatively to assist
11persons who would otherwise lose health benefits as a result
12of changes made under Public Act 98-104 this amendatory Act of
13the 98th General Assembly to transition to other health
14insurance coverage.
15(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
16revised 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
19rule, shall determine the quantity and quality of and the rate
20of reimbursement for the medical assistance for which payment
21will be authorized, and the medical services to be provided,
22which may include all or part of the following: (1) inpatient
23hospital services; (2) outpatient hospital services; (3) other
24laboratory and X-ray services; (4) skilled nursing home
25services; (5) physicians' services whether furnished in the

 

 

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

 

 

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1tool, or process that all must utilize; (14) transportation
2and such other expenses as may be necessary; (15) medical
3treatment of sexual assault survivors, as defined in Section
41a of the Sexual Assault Survivors Emergency Treatment Act,
5for injuries sustained as a result of the sexual assault,
6including examinations and laboratory tests to discover
7evidence which may be used in criminal proceedings arising
8from the sexual assault; (16) the diagnosis and treatment of
9sickle cell anemia; and (17) any other medical care, and any
10other type of remedial care recognized under the laws of this
11State. The term "any other type of remedial care" shall
12include nursing care and nursing home service for persons who
13rely on treatment by spiritual means alone through prayer for
14healing.
15    Notwithstanding any other provision of this Section, a
16comprehensive tobacco use cessation program that includes
17purchasing prescription drugs or prescription medical devices
18approved by the Food and Drug Administration shall be covered
19under the medical assistance program under this Article for
20persons who are otherwise eligible for assistance under this
21Article.
22    Notwithstanding any other provision of this Code,
23reproductive health care that is otherwise legal in Illinois
24shall be covered under the medical assistance program for
25persons who are otherwise eligible for medical assistance
26under this Article.

 

 

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1    Notwithstanding any other provision of this Code, the
2Illinois Department may not require, as a condition of payment
3for any laboratory test authorized under this Article, that a
4physician's handwritten signature appear on the laboratory
5test order form. The Illinois Department may, however, impose
6other appropriate requirements regarding laboratory test order
7documentation.
8    Upon receipt of federal approval of an amendment to the
9Illinois Title XIX State Plan for this purpose, the Department
10shall authorize the Chicago Public Schools (CPS) to procure a
11vendor or vendors to manufacture eyeglasses for individuals
12enrolled in a school within the CPS system. CPS shall ensure
13that its vendor or vendors are enrolled as providers in the
14medical assistance program and in any capitated Medicaid
15managed care entity (MCE) serving individuals enrolled in a
16school within the CPS system. Under any contract procured
17under this provision, the vendor or vendors must serve only
18individuals enrolled in a school within the CPS system. Claims
19for services provided by CPS's vendor or vendors to recipients
20of benefits in the medical assistance program under this Code,
21the Children's Health Insurance Program, or the Covering ALL
22KIDS Health Insurance Program shall be submitted to the
23Department or the MCE in which the individual is enrolled for
24payment and shall be reimbursed at the Department's or the
25MCE's established rates or rate methodologies for eyeglasses.
26    On and after July 1, 2012, the Department of Healthcare

 

 

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1and Family Services may provide the following services to
2persons eligible for assistance under this Article who are
3participating in education, training or employment programs
4operated by the Department of Human Services as successor to
5the 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
12and Family Services shall provide dental services to any adult
13who is otherwise eligible for assistance under the medical
14assistance program. As used in this paragraph, "dental
15services" means diagnostic, preventative, restorative, or
16corrective procedures, including procedures and services for
17the prevention and treatment of periodontal disease and dental
18caries disease, provided by an individual who is licensed to
19practice dentistry or dental surgery or who is under the
20supervision of a dentist in the practice of his or her
21profession.
22    On and after July 1, 2018, targeted dental services, as
23set forth in Exhibit D of the Consent Decree entered by the
24United States District Court for the Northern District of
25Illinois, Eastern Division, in the matter of Memisovski v.
26Maram, Case No. 92 C 1982, that are provided to adults under

 

 

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1the medical assistance program shall be established at no less
2than the rates set forth in the "New Rate" column in Exhibit D
3of the Consent Decree for targeted dental services that are
4provided to persons under the age of 18 under the medical
5assistance program.
6    Notwithstanding any other provision of this Code and
7subject to federal approval, the Department may adopt rules to
8allow a dentist who is volunteering his or her service at no
9cost to render dental services through an enrolled
10not-for-profit health clinic without the dentist personally
11enrolling as a participating provider in the medical
12assistance program. A not-for-profit health clinic shall
13include a public health clinic or Federally Qualified Health
14Center or other enrolled provider, as determined by the
15Department, through which dental services covered under this
16Section are performed. The Department shall establish a
17process for payment of claims for reimbursement for covered
18dental services rendered under this provision.
19    The Illinois Department, by rule, may distinguish and
20classify the medical services to be provided only in
21accordance with the classes of persons designated in Section
225-2.
23    The Department of Healthcare and Family Services must
24provide coverage and reimbursement for amino acid-based
25elemental formulas, regardless of delivery method, for the
26diagnosis and treatment of (i) eosinophilic disorders and (ii)

 

 

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1short bowel syndrome when the prescribing physician has issued
2a written order stating that the amino acid-based elemental
3formula is medically necessary.
4    The Illinois Department shall authorize the provision of,
5and shall authorize payment for, screening by low-dose
6mammography for the presence of occult breast cancer for
7individuals women 35 years of age or older who are eligible for
8medical 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,
6copayment, or any other cost-sharing requirement on the
7coverage provided under this paragraph; except that this
8sentence does not apply to coverage of diagnostic mammograms
9to the extent such coverage would disqualify a high-deductible
10health plan from eligibility for a health savings account
11pursuant to Section 223 of the Internal Revenue Code (26
12U.S.C. 223).
13    All screenings shall include a physical breast exam,
14instruction on self-examination and information regarding the
15frequency of self-examination and its value as a preventative
16tool.
17     For purposes of this Section:
18    "Diagnostic mammogram" means a mammogram obtained using
19diagnostic mammography.
20    "Diagnostic mammography" means a method of screening that
21is designed to evaluate an abnormality in a breast, including
22an abnormality seen or suspected on a screening mammogram or a
23subjective or objective abnormality otherwise detected in the
24breast.
25    "Low-dose mammography" means the x-ray examination of the
26breast using equipment dedicated specifically for mammography,

 

 

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1including the x-ray tube, filter, compression device, and
2image receptor, with an average radiation exposure delivery of
3less than one rad per breast for 2 views of an average size
4breast. The term also includes digital mammography and
5includes breast tomosynthesis.
6    "Breast tomosynthesis" means a radiologic procedure that
7involves the acquisition of projection images over the
8stationary breast to produce cross-sectional digital
9three-dimensional images of the breast.
10    If, at any time, the Secretary of the United States
11Department of Health and Human Services, or its successor
12agency, promulgates rules or regulations to be published in
13the Federal Register or publishes a comment in the Federal
14Register or issues an opinion, guidance, or other action that
15would require the State, pursuant to any provision of the
16Patient Protection and Affordable Care Act (Public Law
17111-148), including, but not limited to, 42 U.S.C.
1818031(d)(3)(B) or any successor provision, to defray the cost
19of any coverage for breast tomosynthesis outlined in this
20paragraph, then the requirement that an insurer cover breast
21tomosynthesis is inoperative other than any such coverage
22authorized under Section 1902 of the Social Security Act, 42
23U.S.C. 1396a, and the State shall not assume any obligation
24for the cost of coverage for breast tomosynthesis set forth in
25this paragraph.
26    On and after January 1, 2016, the Department shall ensure

 

 

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1that all networks of care for adult clients of the Department
2include access to at least one breast imaging Center of
3Imaging Excellence as certified by the American College of
4Radiology.
5    On and after January 1, 2012, providers participating in a
6quality improvement program approved by the Department shall
7be reimbursed for screening and diagnostic mammography at the
8same rate as the Medicare program's rates, including the
9increased reimbursement for digital mammography.
10    The Department shall convene an expert panel including
11representatives of hospitals, free-standing mammography
12facilities, and doctors, including radiologists, to establish
13quality standards for mammography.
14    On and after January 1, 2017, providers participating in a
15breast cancer treatment quality improvement program approved
16by the Department shall be reimbursed for breast cancer
17treatment at a rate that is no lower than 95% of the Medicare
18program's rates for the data elements included in the breast
19cancer treatment quality program.
20    The Department shall convene an expert panel, including
21representatives of hospitals, free-standing breast cancer
22treatment centers, breast cancer quality organizations, and
23doctors, including breast surgeons, reconstructive breast
24surgeons, oncologists, and primary care providers to establish
25quality standards for breast cancer treatment.
26    Subject to federal approval, the Department shall

 

 

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1establish a rate methodology for mammography at federally
2qualified health centers and other encounter-rate clinics.
3These clinics or centers may also collaborate with other
4hospital-based mammography facilities. By January 1, 2016, the
5Department shall report to the General Assembly on the status
6of the provision set forth in this paragraph.
7    The Department shall establish a methodology to remind
8individuals women who are age-appropriate for screening
9mammography, but who have not received a mammogram within the
10previous 18 months, of the importance and benefit of screening
11mammography. The Department shall work with experts in breast
12cancer outreach and patient navigation to optimize these
13reminders and shall establish a methodology for evaluating
14their effectiveness and modifying the methodology based on the
15evaluation.
16    The Department shall establish a performance goal for
17primary care providers with respect to their female patients
18over age 40 receiving an annual mammogram. This performance
19goal shall be used to provide additional reimbursement in the
20form of a quality performance bonus to primary care providers
21who meet that goal.
22    The Department shall devise a means of case-managing or
23patient navigation for beneficiaries diagnosed with breast
24cancer. This program shall initially operate as a pilot
25program in areas of the State with the highest incidence of
26mortality related to breast cancer. At least one pilot program

 

 

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1site shall be in the metropolitan Chicago area and at least one
2site shall be outside the metropolitan Chicago area. On or
3after July 1, 2016, the pilot program shall be expanded to
4include one site in western Illinois, one site in southern
5Illinois, one site in central Illinois, and 4 sites within
6metropolitan Chicago. An evaluation of the pilot program shall
7be carried out measuring health outcomes and cost of care for
8those served by the pilot program compared to similarly
9situated patients who are not served by the pilot program.
10    The Department shall require all networks of care to
11develop a means either internally or by contract with experts
12in navigation and community outreach to navigate cancer
13patients to comprehensive care in a timely fashion. The
14Department shall require all networks of care to include
15access for patients diagnosed with cancer to at least one
16academic commission on cancer-accredited cancer program as an
17in-network covered benefit.
18    On or after July 1, 2022, individuals who are otherwise
19eligible for medical assistance under this Article shall
20receive coverage for perinatal depression screenings for the
2112-month period beginning on the last day of their pregnancy.
22Medical assistance coverage under this paragraph shall be
23conditioned on the use of a screening instrument approved by
24the Department.
25    Any medical or health care provider shall immediately
26recommend, to any pregnant individual woman who is being

 

 

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1provided prenatal services and is suspected of having a
2substance use disorder as defined in the Substance Use
3Disorder Act, referral to a local substance use disorder
4treatment program licensed by the Department of Human Services
5or to a licensed hospital which provides substance abuse
6treatment services. The Department of Healthcare and Family
7Services shall assure coverage for the cost of treatment of
8the drug abuse or addiction for pregnant recipients in
9accordance with the Illinois Medicaid Program in conjunction
10with the Department of Human Services.
11    All medical providers providing medical assistance to
12pregnant individuals women under this Code shall receive
13information from the Department on the availability of
14services under any program providing case management services
15for addicted individuals women, including information on
16appropriate referrals for other social services that may be
17needed by addicted individuals women in addition to treatment
18for addiction.
19    The Illinois Department, in cooperation with the
20Departments of Human Services (as successor to the Department
21of Alcoholism and Substance Abuse) and Public Health, through
22a public awareness campaign, may provide information
23concerning treatment for alcoholism and drug abuse and
24addiction, prenatal health care, and other pertinent programs
25directed at reducing the number of drug-affected infants born
26to recipients of medical assistance.

 

 

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1    Neither the Department of Healthcare and Family Services
2nor the Department of Human Services shall sanction the
3recipient solely on the basis of the recipient's her substance
4abuse.
5    The Illinois Department shall establish such regulations
6governing the dispensing of health services under this Article
7as it shall deem appropriate. The Department should seek the
8advice of formal professional advisory committees appointed by
9the Director of the Illinois Department for the purpose of
10providing regular advice on policy and administrative matters,
11information dissemination and educational activities for
12medical and health care providers, and consistency in
13procedures to the Illinois Department.
14    The Illinois Department may develop and contract with
15Partnerships of medical providers to arrange medical services
16for persons eligible under Section 5-2 of this Code.
17Implementation of this Section may be by demonstration
18projects in certain geographic areas. The Partnership shall be
19represented by a sponsor organization. The Department, by
20rule, shall develop qualifications for sponsors of
21Partnerships. Nothing in this Section shall be construed to
22require that the sponsor organization be a medical
23organization.
24    The sponsor must negotiate formal written contracts with
25medical providers for physician services, inpatient and
26outpatient hospital care, home health services, treatment for

 

 

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1alcoholism and substance abuse, and other services determined
2necessary by the Illinois Department by rule for delivery by
3Partnerships. Physician services must include prenatal and
4obstetrical care. The Illinois Department shall reimburse
5medical services delivered by Partnership providers to clients
6in target areas according to provisions of this Article and
7the 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
21qualifications to participate in Partnerships to ensure the
22delivery of high quality medical services. These
23qualifications shall be determined by rule of the Illinois
24Department and may be higher than qualifications for
25participation in the medical assistance program. Partnership
26sponsors may prescribe reasonable additional qualifications

 

 

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

 

 

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

 

 

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1the acquisition costs of all prescription drugs shall be
2updated no less frequently than every 30 days as required by
3Section 5-5.12.
4    Notwithstanding any other law to the contrary, the
5Illinois Department shall, within 365 days after July 22, 2013
6(the effective date of Public Act 98-104), establish
7procedures to permit skilled care facilities licensed under
8the Nursing Home Care Act to submit monthly billing claims for
9reimbursement purposes. Following development of these
10procedures, the Department shall, by July 1, 2016, test the
11viability of the new system and implement any necessary
12operational or structural changes to its information
13technology platforms in order to allow for the direct
14acceptance and payment of nursing home claims.
15    Notwithstanding any other law to the contrary, the
16Illinois Department shall, within 365 days after August 15,
172014 (the effective date of Public Act 98-963), establish
18procedures to permit ID/DD facilities licensed under the ID/DD
19Community Care Act and MC/DD facilities licensed under the
20MC/DD Act to submit monthly billing claims for reimbursement
21purposes. Following development of these procedures, the
22Department shall have an additional 365 days to test the
23viability of the new system and to ensure that any necessary
24operational or structural changes to its information
25technology platforms are implemented.
26    The Illinois Department shall require all dispensers of

 

 

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1medical services, other than an individual practitioner or
2group of practitioners, desiring to participate in the Medical
3Assistance program established under this Article to disclose
4all financial, beneficial, ownership, equity, surety or other
5interests in any and all firms, corporations, partnerships,
6associations, business enterprises, joint ventures, agencies,
7institutions or other legal entities providing any form of
8health care services in this State under this Article.
9    The Illinois Department may require that all dispensers of
10medical services desiring to participate in the medical
11assistance program established under this Article disclose,
12under such terms and conditions as the Illinois Department may
13by rule establish, all inquiries from clients and attorneys
14regarding medical bills paid by the Illinois Department, which
15inquiries could indicate potential existence of claims or
16liens for the Illinois Department.
17    Enrollment of a vendor shall be subject to a provisional
18period and shall be conditional for one year. During the
19period of conditional enrollment, the Department may terminate
20the vendor's eligibility to participate in, or may disenroll
21the vendor from, the medical assistance program without cause.
22Unless otherwise specified, such termination of eligibility or
23disenrollment is not subject to the Department's hearing
24process. However, a disenrolled vendor may reapply without
25penalty.
26    The Department has the discretion to limit the conditional

 

 

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1enrollment period for vendors based upon category of risk of
2the vendor.
3    Prior to enrollment and during the conditional enrollment
4period in the medical assistance program, all vendors shall be
5subject to enhanced oversight, screening, and review based on
6the risk of fraud, waste, and abuse that is posed by the
7category of risk of the vendor. The Illinois Department shall
8establish the procedures for oversight, screening, and review,
9which may include, but need not be limited to: criminal and
10financial background checks; fingerprinting; license,
11certification, and authorization verifications; unscheduled or
12unannounced site visits; database checks; prepayment audit
13reviews; audits; payment caps; payment suspensions; and other
14screening as required by federal or State law.
15    The Department shall define or specify the following: (i)
16by provider notice, the "category of risk of the vendor" for
17each type of vendor, which shall take into account the level of
18screening applicable to a particular category of vendor under
19federal law and regulations; (ii) by rule or provider notice,
20the maximum length of the conditional enrollment period for
21each category of risk of the vendor; and (iii) by rule, the
22hearing rights, if any, afforded to a vendor in each category
23of risk of the vendor that is terminated or disenrolled during
24the conditional enrollment period.
25    To be eligible for payment consideration, a vendor's
26payment claim or bill, either as an initial claim or as a

 

 

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1resubmitted claim following prior rejection, must be received
2by the Illinois Department, or its fiscal intermediary, no
3later than 180 days after the latest date on the claim on which
4medical goods or services were provided, with the following
5exceptions:
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
23a recipient received retroactive eligibility, claims must be
24filed within 180 days after the Department determines the
25applicant is eligible. For claims for which the Illinois
26Department is not the primary payer, claims must be submitted

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1development of non-institutional services in areas of the
2State where they are not currently available or are
3undeveloped; and (iii) notwithstanding any other provision of
4law, subject to federal approval, on and after July 1, 2012, an
5increase in the determination of need (DON) scores from 29 to
637 for applicants for institutional and home and
7community-based long term care; if and only if federal
8approval is not granted, the Department may, in conjunction
9with other affected agencies, implement utilization controls
10or changes in benefit packages to effectuate a similar savings
11amount for this population; and (iv) no later than July 1,
122013, minimum level of care eligibility criteria for
13institutional and home and community-based long term care; and
14(v) no later than October 1, 2013, establish procedures to
15permit long term care providers access to eligibility scores
16for individuals with an admission date who are seeking or
17receiving services from the long term care provider. In order
18to select the minimum level of care eligibility criteria, the
19Governor shall establish a workgroup that includes affected
20agency representatives and stakeholders representing the
21institutional and home and community-based long term care
22interests. This Section shall not restrict the Department from
23implementing lower level of care eligibility criteria for
24community-based services in circumstances where federal
25approval has been granted.
26    The Illinois Department shall develop and operate, in

 

 

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1cooperation with other State Departments and agencies and in
2compliance with applicable federal laws and regulations,
3appropriate and effective systems of health care evaluation
4and programs for monitoring of utilization of health care
5services and facilities, as it affects persons eligible for
6medical assistance under this Code.
7    The Illinois Department shall report annually to the
8General Assembly, no later than the second Friday in April of
91979 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
19ending on the June 30 prior to the report. The report shall
20include suggested legislation for consideration by the General
21Assembly. The requirement for reporting to the General
22Assembly shall be satisfied by filing copies of the report as
23required by Section 3.1 of the General Assembly Organization
24Act, and filing such additional copies with the State
25Government Report Distribution Center for the General Assembly
26as is required under paragraph (t) of Section 7 of the State

 

 

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

 

 

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

 

 

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1coverage and reimbursement for all drugs that are approved for
2marketing by the federal Food and Drug Administration and that
3are recommended by the federal Public Health Service or the
4United States Centers for Disease Control and Prevention for
5pre-exposure prophylaxis and related pre-exposure prophylaxis
6services, including, but not limited to, HIV and sexually
7transmitted infection screening, treatment for sexually
8transmitted infections, medical monitoring, assorted labs, and
9counseling to reduce the likelihood of HIV infection among
10individuals who are not infected with HIV but who are at high
11risk of HIV infection.
12    A federally qualified health center, as defined in Section
131905(l)(2)(B) of the federal Social Security Act, shall be
14reimbursed by the Department in accordance with the federally
15qualified health center's encounter rate for services provided
16to medical assistance recipients that are performed by a
17dental hygienist, as defined under the Illinois Dental
18Practice Act, working under the general supervision of a
19dentist and employed by a federally qualified health center.
20    Within 90 days after the effective date of this amendatory
21Act of the 102nd General Assembly, the Department shall seek
22federal approval of a State Plan amendment to expand coverage
23for family planning services that includes presumptive
24eligibility to individuals whose income is at or below 208% of
25the federal poverty level. Coverage under this Section shall
26be 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;
2100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
36-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
4eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
5100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
61-1-20; revised 9-18-19.)
 
7    (305 ILCS 5/5-5.24)
8    Sec. 5-5.24. Prenatal and perinatal care. The Department
9of Healthcare and Family Services may provide reimbursement
10under this Article for all prenatal and perinatal health care
11services that are provided for the purpose of preventing
12low-birthweight infants, reducing the need for neonatal
13intensive care hospital services, and promoting perinatal and
14maternal health. These services may include comprehensive risk
15assessments for pregnant individuals women, individuals women
16with infants, and infants, lactation counseling, nutrition
17counseling, childbirth support, psychosocial counseling,
18treatment and prevention of periodontal disease, language
19translation, nurse home visitation, and other support services
20that have been proven to improve birth and maternal health
21outcomes. The Department shall maximize the use of preventive
22prenatal and perinatal health care services consistent with
23federal statutes, rules, and regulations. The Department of
24Public Aid (now Department of Healthcare and Family Services)
25shall develop a plan for prenatal and perinatal preventive

 

 

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1health care and shall present the plan to the General Assembly
2by January 1, 2004. On or before January 1, 2006 and every 2
3years thereafter, the Department shall report to the General
4Assembly concerning the effectiveness of prenatal and
5perinatal health care services reimbursed under this Section
6in preventing low-birthweight infants and reducing the need
7for neonatal intensive care hospital services. Each such
8report shall include an evaluation of how the ratio of
9expenditures for treating low-birthweight infants compared
10with the investment in promoting healthy births and infants in
11local community areas throughout Illinois relates to healthy
12infant development in those areas.
13    On and after July 1, 2012, the Department shall reduce any
14rate of reimbursement for services or other payments or alter
15any methodologies authorized by this Code to reduce any rate
16of reimbursement for services or other payments in accordance
17with 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
23professional in lactation counseling who has demonstrated the
24necessary skills, knowledge, and attitudes to provide clinical
25breastfeeding counseling and management support to families

 

 

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1who are thinking about breastfeeding or who have questions or
2problems during the course of breastfeeding.
3    "Certified nurse midwife" means a person who exceeds the
4competencies for a midwife contained in the Essential
5Competencies for Midwifery Practice, published by the
6International Confederation of Midwives, and who qualifies as
7an advanced practice registered nurse.
8    "Community health worker" means a frontline public health
9worker who is a trusted member or has an unusually close
10understanding of the community served. This trusting
11relationship enables the community health worker to serve as a
12liaison, link, and intermediary between health and social
13services and the community to facilitate access to services
14and improve the quality and cultural competence of service
15delivery.
16    "International board-certified lactation consultant"
17means a health care professional who is certified by the
18International Board of Lactation Consultant Examiners and
19specializes in the clinical management of breastfeeding.
20    "Medical caseworker" means a health care professional who
21assists in the planning, coordination, monitoring, and
22evaluation of medical services for a patient with emphasis on
23quality of care, continuity of services, and affordability.
24    "Perinatal doula" means a trained provider of regular and
25voluntary physical, emotional, and educational support, but
26not medical or midwife care, to pregnant and birthing persons

 

 

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1before, during, and after childbirth, otherwise known as the
2perinatal period.
3    "Public health nurse" means a registered nurse who
4promotes and protects the health of populations using
5knowledge from nursing, social, and public health sciences.
6    (b) The Illinois Department shall establish a medical
7assistance program to cover a universal postpartum visit
8within the first 3 weeks after childbirth and a comprehensive
9visit within 4 to 12 weeks postpartum for persons who are
10otherwise eligible for medical assistance under this Article.
11In addition, postpartum care services rendered by perinatal
12doulas, certified lactation counselors, international
13board-certified lactation consultants, public health nurses,
14certified nurse midwives, community health workers, and
15medical caseworkers shall be covered under the medical
16assistance program.
 
17    Section 99. Effective date. This Act takes effect upon
18becoming law.