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

SB0967sam002 102ND GENERAL ASSEMBLY

Sen. Cristina Castro

Filed: 5/10/2021

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 967

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

 

 

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

 

 

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

 

 

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

 

 

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1organization shall consider existing programs, such as the
2Alliance for Innovation on Maternal Health and the California
3Maternal Quality Collaborative's pilot work on improving birth
4equity. The Department shall support the initiation of a
5statewide perinatal quality improvement initiative in
6collaboration with birthing facilities to implement strategies
7to reduce peripartum racial and ethnic disparities and to
8address implicit bias in the health care system.
9    (d) In order to better facilitate continuity of care, the
10The Department, in consultation with the Illinois Perinatal
11Quality Collaborative Maternal Mortality Review Committee,
12shall make available to all birthing facilities best practices
13for timely identification and assessment of all pregnant and
14postpartum women for common pregnancy or postpartum
15complications in the emergency department and for care
16provided by the birthing facility throughout the pregnancy and
17postpartum period. The best practices shall include the
18appropriate and timely consultation of an obstetric or other
19relevant provider to provide input on management and
20follow-up, such as offering coordination of a post-delivery
21early postpartum visit or other services that may be
22appropriate and available. Birthing facilities shall
23incorporate these best practices into the written policy
24required under subsection (b). Birthing facilities may use
25telemedicine for the consultation.
26    (e) The Department may adopt rules for the purpose of

 

 

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1implementing this Section.
2(Source: P.A. 101-390, eff. 1-1-20; revised 10-7-19.)
 
3    (20 ILCS 2310/2310-470 new)
4    Sec. 2310-470. High Risk Infant Follow-up. The Department,
5in collaboration with the Department of Human Services, the
6Department of Healthcare and Family Services, and other key
7providers of maternal child health services, shall revise or
8add to the rules of the Maternal and Child Health Services Code
9(77 Ill. Adm. Code 630) that govern the High Risk Infant
10Follow-up, using current scientific and national and State
11outcomes data, to revise or expand existing services to
12improve both maternal and infant outcomes overall and to
13reduce racial disparities in outcomes and services provided.
14The rules shall be revised or adopted on or before June 1,
152024.
 
16    Section 20. The Counties Code is amended by changing
17Section 5-1069.3 as follows:
 
18    (55 ILCS 5/5-1069.3)
19    Sec. 5-1069.3. Required health benefits. If a county,
20including a home rule county, is a self-insurer for purposes
21of providing health insurance coverage for its employees, the
22coverage shall include coverage for the post-mastectomy care
23benefits required to be covered by a policy of accident and

 

 

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1health insurance under Section 356t and the coverage required
2under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
3356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
4356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
5356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
6the Illinois Insurance Code. The coverage shall comply with
7Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
8Insurance Code. The Department of Insurance shall enforce the
9requirements of this Section. The requirement that health
10benefits be covered as provided in this Section is an
11exclusive power and function of the State and is a denial and
12limitation under Article VII, Section 6, subsection (h) of the
13Illinois Constitution. A home rule county to which this
14Section applies must comply with every provision of this
15Section.
16    Rulemaking authority to implement Public Act 95-1045, if
17any, is conditioned on the rules being adopted in accordance
18with all provisions of the Illinois Administrative Procedure
19Act and all rules and procedures of the Joint Committee on
20Administrative Rules; any purported rule not so adopted, for
21whatever reason, is unauthorized.
22(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
23100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
241-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
25eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
26101-625, eff. 1-1-21.)
 

 

 

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1    Section 25. The Illinois Municipal Code is amended by
2changing Section 10-4-2.3 as follows:
 
3    (65 ILCS 5/10-4-2.3)
4    Sec. 10-4-2.3. Required health benefits. If a
5municipality, including a home rule municipality, is a
6self-insurer for purposes of providing health insurance
7coverage for its employees, the coverage shall include
8coverage for the post-mastectomy care benefits required to be
9covered by a policy of accident and health insurance under
10Section 356t and the coverage required under Sections 356g,
11356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9,
12356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
13356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
14356z.36, 356z.40, and 356z.41 of the Illinois Insurance Code.
15The coverage shall comply with Sections 155.22a, 355b,
16356z.19, and 370c of the Illinois Insurance Code. The
17Department of Insurance shall enforce the requirements of this
18Section. The requirement that health benefits be covered as
19provided in this is an exclusive power and function of the
20State and is a denial and limitation under Article VII,
21Section 6, subsection (h) of the Illinois Constitution. A home
22rule municipality to which this Section applies must comply
23with every provision of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
7100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
81-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
9eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
10101-625, eff. 1-1-21.)
 
11    Section 30. The School Code is amended by changing Section
1210-22.3f as follows:
 
13    (105 ILCS 5/10-22.3f)
14    Sec. 10-22.3f. Required health benefits. Insurance
15protection and benefits for employees shall provide the
16post-mastectomy care benefits required to be covered by a
17policy of accident and health insurance under Section 356t and
18the coverage required under Sections 356g, 356g.5, 356g.5-1,
19356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
20356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
21356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, and 356z.41 of
22the Illinois Insurance Code. Insurance policies shall comply
23with Section 356z.19 of the Illinois Insurance Code. The
24coverage shall comply with Sections 155.22a, 355b, and 370c of

 

 

10200SB0967sam002- 10 -LRB102 04880 CPF 26303 a

1the Illinois Insurance Code. The Department of Insurance shall
2enforce the requirements of this Section.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
10100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
111-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281,
12eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20;
13101-625, eff. 1-1-21.)
 
14    Section 35. The Illinois Insurance Code is amended by
15adding Sections 356z.4b and 356z.40 as follows:
 
16    (215 ILCS 5/356z.4b new)
17    Sec. 356z.4b. Billing for long-acting reversible
18contraceptives.
19    (a) In this Section, "long-acting reversible contraceptive
20device" means any intrauterine device or contraceptive
21implant.
22    (b) Any individual or group policy of accident and health
23insurance or qualified health plan that is offered through the
24health insurance marketplace that is amended, delivered,

 

 

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1issued, or renewed on or after the effective date of this
2amendatory Act of the 102nd General Assembly shall allow
3hospitals separate reimbursement for a long-acting reversible
4contraceptive device provided immediately postpartum in the
5inpatient hospital setting before hospital discharge. The
6payment shall be made in addition to a bundled or Diagnostic
7Related Group reimbursement for labor and delivery.
 
8    (215 ILCS 5/356z.40 new)
9    Sec. 356z.40. Pregnancy and postpartum coverage.
10    (a) An individual or group policy of accident and health
11insurance or managed care plan amended, delivered, issued, or
12renewed on or after the effective date of this amendatory Act
13of the 102nd General Assembly shall provide coverage for
14pregnancy and newborn care in accordance with 42 U.S.C.
1518022(b) regarding essential health benefits.
16    (b) Benefits under this Section shall be as follows:
17        (1) An individual who has been identified as
18    experiencing a high-risk pregnancy by the individual's
19    treating provider shall have access to clinically
20    appropriate case management programs. As used in this
21    subsection, "case management" means a mechanism to
22    coordinate and assure continuity of services, including,
23    but not limited to, health services, social services, and
24    educational services necessary for the individual. "Case
25    management" involves individualized assessment of needs,

 

 

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1    planning of services, referral, monitoring, and advocacy
2    to assist an individual in gaining access to appropriate
3    services and closure when services are no longer required.
4    "Case management" is an active and collaborative process
5    involving a single qualified case manager, the individual,
6    the individual's family, the providers, and the community.
7    This includes close coordination and involvement with all
8    service providers in the management plan for that
9    individual or family, including assuring that the
10    individual receives the services. As used in this
11    subsection, "high-risk pregnancy" means a pregnancy in
12    which the pregnant or postpartum individual or baby is at
13    an increased risk for poor health or complications during
14    pregnancy or childbirth, including, but not limited to,
15    hypertension disorders, gestational diabetes, and
16    hemorrhage.
17        (2) An individual shall have access to medically
18    necessary treatment of a mental, emotional, nervous, or
19    substance use disorder or condition consistent with the
20    requirements set forth in this Section and in Sections
21    370c and 370c.1 of this Code.
22        (3) The benefits provided for inpatient and outpatient
23    services for the treatment of a mental, emotional,
24    nervous, or substance use disorder or condition related to
25    pregnancy or postpartum complications shall be provided if
26    determined to be medically necessary, consistent with the

 

 

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1    requirements of Sections 370c and 370c.1 of this Code. The
2    facility or provider shall notify the insurer of both the
3    admission and the initial treatment plan within 48 hours
4    after admission or initiation of treatment. Nothing in
5    this paragraph shall prevent an insurer from applying
6    concurrent and post-service utilization review of health
7    care services, including review of medical necessity, case
8    management, experimental and investigational treatments,
9    managed care provisions, and other terms and conditions of
10    the insurance policy.
11        (4) The benefits for the first 48 hours of initiation
12    of services for an inpatient admission, detoxification or
13    withdrawal management program, or partial hospitalization
14    admission for the treatment of a mental, emotional,
15    nervous, or substance use disorder or condition related to
16    pregnancy or postpartum complications shall be provided
17    without post-service or concurrent review of medical
18    necessity, as the medical necessity for the first 48 hours
19    of such services shall be determined solely by the covered
20    pregnant or postpartum individual's provider. Nothing in
21    this paragraph shall prevent an insurer from applying
22    concurrent and post-service utilization review, including
23    the review of medical necessity, case management,
24    experimental and investigational treatments, managed care
25    provisions, and other terms and conditions of the
26    insurance policy, of any inpatient admission,

 

 

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1    detoxification or withdrawal management program admission,
2    or partial hospitalization admission services for the
3    treatment of a mental, emotional, nervous, or substance
4    use disorder or condition related to pregnancy or
5    postpartum complications received 48 hours after the
6    initiation of such services. If an insurer determines that
7    the services are no longer medically necessary, then the
8    covered person shall have the right to external review
9    pursuant to the requirements of the Health Carrier
10    External Review Act.
11        (5) If an insurer determines that continued inpatient
12    care, detoxification or withdrawal management, partial
13    hospitalization, intensive outpatient treatment, or
14    outpatient treatment in a facility is no longer medically
15    necessary, the insurer shall, within 24 hours, provide
16    written notice to the covered pregnant or postpartum
17    individual and the covered pregnant or postpartum
18    individual's provider of its decision and the right to
19    file an expedited internal appeal of the determination.
20    The insurer shall review and make a determination with
21    respect to the internal appeal within 24 hours and
22    communicate such determination to the covered pregnant or
23    postpartum individual and the covered pregnant or
24    postpartum individual's provider. If the determination is
25    to uphold the denial, the covered pregnant or postpartum
26    individual and the covered pregnant or postpartum

 

 

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1    individual's provider have the right to file an expedited
2    external appeal. An independent utilization review
3    organization shall make a determination within 72 hours.
4    If the insurer's determination is upheld and it is
5    determined that continued inpatient care, detoxification
6    or withdrawal management, partial hospitalization,
7    intensive outpatient treatment, or outpatient treatment is
8    not medically necessary, the insurer shall remain
9    responsible for providing benefits for the inpatient care,
10    detoxification or withdrawal management, partial
11    hospitalization, intensive outpatient treatment, or
12    outpatient treatment through the day following the date
13    the determination is made, and the covered pregnant or
14    postpartum individual shall only be responsible for any
15    applicable copayment, deductible, and coinsurance for the
16    stay through that date as applicable under the policy. The
17    covered pregnant or postpartum individual shall not be
18    discharged or released from the inpatient facility,
19    detoxification or withdrawal management, partial
20    hospitalization, intensive outpatient treatment, or
21    outpatient treatment until all internal appeals and
22    independent utilization review organization appeals are
23    exhausted. A decision to reverse an adverse determination
24    shall comply with the Health Carrier External Review Act.
25        (6) Except as otherwise stated in this subsection (b),
26    the benefits and cost-sharing shall be provided to the

 

 

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1    same extent as for any other medical condition covered
2    under the policy.
3        (7) The benefits required by paragraphs (2) and (6) of
4    this subsection (b) are to be provided to all covered
5    pregnant or postpartum individuals with a diagnosis of a
6    mental, emotional, nervous, or substance use disorder or
7    condition. The presence of additional related or unrelated
8    diagnoses shall not be a basis to reduce or deny the
9    benefits required by this subsection (b).
 
10    Section 40. The Health Maintenance Organization Act is
11amended by changing Section 5-3 as follows:
 
12    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
13    Sec. 5-3. Insurance Code provisions.
14    (a) Health Maintenance Organizations shall be subject to
15the provisions of Sections 133, 134, 136, 137, 139, 140,
16141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
17154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
18355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
19356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
20356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
21356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
22356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.40,
23356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
24368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,

 

 

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1408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
2(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
3XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois
4Insurance Code.
5    (b) For purposes of the Illinois Insurance Code, except
6for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
7Health Maintenance Organizations in the following categories
8are deemed to be "domestic companies":
9        (1) a corporation authorized under the Dental Service
10    Plan Act or the Voluntary Health Services Plans Act;
11        (2) a corporation organized under the laws of this
12    State; or
13        (3) a corporation organized under the laws of another
14    state, 30% or more of the enrollees of which are residents
15    of this State, except a corporation subject to
16    substantially the same requirements in its state of
17    organization as is a "domestic company" under Article VIII
18    1/2 of the Illinois Insurance Code.
19    (c) In considering the merger, consolidation, or other
20acquisition of control of a Health Maintenance Organization
21pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22        (1) the Director shall give primary consideration to
23    the continuation of benefits to enrollees and the
24    financial conditions of the acquired Health Maintenance
25    Organization after the merger, consolidation, or other
26    acquisition of control takes effect;

 

 

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

 

 

10200SB0967sam002- 19 -LRB102 04880 CPF 26303 a

1Insurance Code and this Section 5-3 shall apply to the sale by
2any health maintenance organization of greater than 10% of its
3enrollee population (including without limitation the health
4maintenance organization's right, title, and interest in and
5to its health care certificates).
6    (e) In considering any management contract or service
7agreement subject to Section 141.1 of the Illinois Insurance
8Code, the Director (i) shall, in addition to the criteria
9specified in Section 141.2 of the Illinois Insurance Code,
10take into account the effect of the management contract or
11service agreement on the continuation of benefits to enrollees
12and the financial condition of the health maintenance
13organization to be managed or serviced, and (ii) need not take
14into account the effect of the management contract or service
15agreement on competition.
16    (f) Except for small employer groups as defined in the
17Small Employer Rating, Renewability and Portability Health
18Insurance Act and except for medicare supplement policies as
19defined in Section 363 of the Illinois Insurance Code, a
20Health Maintenance Organization may by contract agree with a
21group or other enrollment unit to effect refunds or charge
22additional premiums under the following terms and conditions:
23        (i) the amount of, and other terms and conditions with
24    respect to, the refund or additional premium are set forth
25    in the group or enrollment unit contract agreed in advance
26    of the period for which a refund is to be paid or

 

 

10200SB0967sam002- 20 -LRB102 04880 CPF 26303 a

1    additional premium is to be charged (which period shall
2    not be less than one year); and
3        (ii) the amount of the refund or additional premium
4    shall not exceed 20% of the Health Maintenance
5    Organization's profitable or unprofitable experience with
6    respect to the group or other enrollment unit for the
7    period (and, for purposes of a refund or additional
8    premium, the profitable or unprofitable experience shall
9    be calculated taking into account a pro rata share of the
10    Health Maintenance Organization's administrative and
11    marketing expenses, but shall not include any refund to be
12    made or additional premium to be paid pursuant to this
13    subsection (f)). The Health Maintenance Organization and
14    the group or enrollment unit may agree that the profitable
15    or unprofitable experience may be calculated taking into
16    account the refund period and the immediately preceding 2
17    plan years.
18    The Health Maintenance Organization shall include a
19statement in the evidence of coverage issued to each enrollee
20describing the possibility of a refund or additional premium,
21and upon request of any group or enrollment unit, provide to
22the group or enrollment unit a description of the method used
23to calculate (1) the Health Maintenance Organization's
24profitable experience with respect to the group or enrollment
25unit and the resulting refund to the group or enrollment unit
26or (2) the Health Maintenance Organization's unprofitable

 

 

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1experience with respect to the group or enrollment unit and
2the resulting additional premium to be paid by the group or
3enrollment unit.
4    In no event shall the Illinois Health Maintenance
5Organization Guaranty Association be liable to pay any
6contractual obligation of an insolvent organization to pay any
7refund authorized under this Section.
8    (g) Rulemaking authority to implement Public Act 95-1045,
9if any, is conditioned on the rules being adopted in
10accordance with all provisions of the Illinois Administrative
11Procedure Act and all rules and procedures of the Joint
12Committee on Administrative Rules; any purported rule not so
13adopted, for whatever reason, is unauthorized.
14(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
15100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
161-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
17eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;
18101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
191-1-20; 101-625, eff. 1-1-21.)
 
20    Section 45. The Voluntary Health Services Plans Act is
21amended by changing Section 10 as follows:
 
22    (215 ILCS 165/10)  (from Ch. 32, par. 604)
23    Sec. 10. Application of Insurance Code provisions. Health
24services plan corporations and all persons interested therein

 

 

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1or dealing therewith shall be subject to the provisions of
2Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
3143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
4356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x,
5356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
6356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
7356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29,
8356z.30, 356z.30a, 356z.32, 356z.33, 356z.40, 356z.41, 364.01,
9367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
10and paragraphs (7) and (15) of Section 367 of the Illinois
11Insurance Code.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
19100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
201-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
21eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
22101-625, eff. 1-1-21.)
 
23    Section 50. The Illinois Public Aid Code is amended by
24changing Sections 5-2, 5-5, and 5-5.24 and by adding Section
255-18.10 as follows:
 

 

 

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1    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
2    Sec. 5-2. Classes of persons eligible. Medical assistance
3under this Article shall be available to any of the following
4classes of persons in respect to whom a plan for coverage has
5been submitted to the Governor by the Illinois Department and
6approved by him. If changes made in this Section 5-2 require
7federal approval, they shall not take effect until such
8approval has been received:
9        1. Recipients of basic maintenance grants under
10    Articles III and IV.
11        2. Beginning January 1, 2014, persons otherwise
12    eligible for basic maintenance under Article III,
13    excluding any eligibility requirements that are
14    inconsistent with any federal law or federal regulation,
15    as interpreted by the U.S. Department of Health and Human
16    Services, but who fail to qualify thereunder on the basis
17    of need, and who have insufficient income and resources to
18    meet the costs of necessary medical care, including, but
19    not limited to, the following:
20            (a) All persons otherwise eligible for basic
21        maintenance under Article III but who fail to qualify
22        under that Article on the basis of need and who meet
23        either of the following requirements:
24                (i) their income, as determined by the
25            Illinois Department in accordance with any federal

 

 

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1            requirements, is equal to or less than 100% of the
2            federal poverty level; or
3                (ii) their income, after the deduction of
4            costs incurred for medical care and for other
5            types of remedial care, is equal to or less than
6            100% of the federal poverty level.
7            (b) (Blank).
8        3. (Blank).
9        4. Persons not eligible under any of the preceding
10    paragraphs who fall sick, are injured, or die, not having
11    sufficient money, property or other resources to meet the
12    costs of necessary medical care or funeral and burial
13    expenses.
14        5.(a) Beginning January 1, 2020, individuals women
15    during pregnancy and during the 12-month period beginning
16    on the last day of the pregnancy, together with their
17    infants, whose income is at or below 200% of the federal
18    poverty level. Until September 30, 2019, or sooner if the
19    maintenance of effort requirements under the Patient
20    Protection and Affordable Care Act are eliminated or may
21    be waived before then, individuals women during pregnancy
22    and during the 12-month period beginning on the last day
23    of the pregnancy, whose countable monthly income, after
24    the deduction of costs incurred for medical care and for
25    other types of remedial care as specified in
26    administrative rule, is equal to or less than the Medical

 

 

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1    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
2    on April 1, 2013 as set forth in administrative rule.
3        (b) The plan for coverage shall provide ambulatory
4    prenatal care to pregnant individuals women during a
5    presumptive eligibility period and establish an income
6    eligibility standard that is equal to 200% of the federal
7    poverty level, provided that costs incurred for medical
8    care are not taken into account in determining such income
9    eligibility.
10        (c) The Illinois Department may conduct a
11    demonstration in at least one county that will provide
12    medical assistance to pregnant individuals women, together
13    with their infants and children up to one year of age,
14    where the income eligibility standard is set up to 185% of
15    the nonfarm income official poverty line, as defined by
16    the federal Office of Management and Budget. The Illinois
17    Department shall seek and obtain necessary authorization
18    provided under federal law to implement such a
19    demonstration. Such demonstration may establish resource
20    standards that are not more restrictive than those
21    established under Article IV of this Code.
22        6. (a) Children younger than age 19 when countable
23    income is at or below 133% of the federal poverty level.
24    Until September 30, 2019, or sooner if the maintenance of
25    effort requirements under the Patient Protection and
26    Affordable Care Act are eliminated or may be waived before

 

 

10200SB0967sam002- 26 -LRB102 04880 CPF 26303 a

1    then, children younger than age 19 whose countable monthly
2    income, after the deduction of costs incurred for medical
3    care and for other types of remedial care as specified in
4    administrative rule, is equal to or less than the Medical
5    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
6    on April 1, 2013 as set forth in administrative rule.
7        (b) Children and youth who are under temporary custody
8    or guardianship of the Department of Children and Family
9    Services or who receive financial assistance in support of
10    an adoption or guardianship placement from the Department
11    of Children and Family Services.
12        7. (Blank).
13        8. As required under federal law, persons who are
14    eligible for Transitional Medical Assistance as a result
15    of an increase in earnings or child or spousal support
16    received. The plan for coverage for this class of persons
17    shall:
18            (a) extend the medical assistance coverage to the
19        extent required by federal law; and
20            (b) offer persons who have initially received 6
21        months of the coverage provided in paragraph (a)
22        above, the option of receiving an additional 6 months
23        of coverage, subject to the following:
24                (i) such coverage shall be pursuant to
25            provisions of the federal Social Security Act;
26                (ii) such coverage shall include all services

 

 

10200SB0967sam002- 27 -LRB102 04880 CPF 26303 a

1            covered under Illinois' State Medicaid Plan;
2                (iii) no premium shall be charged for such
3            coverage; and
4                (iv) such coverage shall be suspended in the
5            event of a person's failure without good cause to
6            file in a timely fashion reports required for this
7            coverage under the Social Security Act and
8            coverage shall be reinstated upon the filing of
9            such reports if the person remains otherwise
10            eligible.
11        9. Persons with acquired immunodeficiency syndrome
12    (AIDS) or with AIDS-related conditions with respect to
13    whom there has been a determination that but for home or
14    community-based services such individuals would require
15    the level of care provided in an inpatient hospital,
16    skilled nursing facility or intermediate care facility the
17    cost of which is reimbursed under this Article. Assistance
18    shall be provided to such persons to the maximum extent
19    permitted under Title XIX of the Federal Social Security
20    Act.
21        10. Participants in the long-term care insurance
22    partnership program established under the Illinois
23    Long-Term Care Partnership Program Act who meet the
24    qualifications for protection of resources described in
25    Section 15 of that Act.
26        11. Persons with disabilities who are employed and

 

 

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1    eligible for Medicaid, pursuant to Section
2    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
3    subject to federal approval, persons with a medically
4    improved disability who are employed and eligible for
5    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
6    the Social Security Act, as provided by the Illinois
7    Department by rule. In establishing eligibility standards
8    under this paragraph 11, the Department shall, subject to
9    federal approval:
10            (a) set the income eligibility standard at not
11        lower than 350% of the federal poverty level;
12            (b) exempt retirement accounts that the person
13        cannot access without penalty before the age of 59
14        1/2, and medical savings accounts established pursuant
15        to 26 U.S.C. 220;
16            (c) allow non-exempt assets up to $25,000 as to
17        those assets accumulated during periods of eligibility
18        under this paragraph 11; and
19            (d) continue to apply subparagraphs (b) and (c) in
20        determining the eligibility of the person under this
21        Article even if the person loses eligibility under
22        this paragraph 11.
23        12. Subject to federal approval, persons who are
24    eligible for medical assistance coverage under applicable
25    provisions of the federal Social Security Act and the
26    federal Breast and Cervical Cancer Prevention and

 

 

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1    Treatment Act of 2000. Those eligible persons are defined
2    to include, but not be limited to, the following persons:
3            (1) persons who have been screened for breast or
4        cervical cancer under the U.S. Centers for Disease
5        Control and Prevention Breast and Cervical Cancer
6        Program established under Title XV of the federal
7        Public Health Service Services Act in accordance with
8        the requirements of Section 1504 of that Act as
9        administered by the Illinois Department of Public
10        Health; and
11            (2) persons whose screenings under the above
12        program were funded in whole or in part by funds
13        appropriated to the Illinois Department of Public
14        Health for breast or cervical cancer screening.
15        "Medical assistance" under this paragraph 12 shall be
16    identical to the benefits provided under the State's
17    approved plan under Title XIX of the Social Security Act.
18    The Department must request federal approval of the
19    coverage under this paragraph 12 within 30 days after July
20    3, 2001 (the effective date of Public Act 92-47) this
21    amendatory Act of the 92nd General Assembly.
22        In addition to the persons who are eligible for
23    medical assistance pursuant to subparagraphs (1) and (2)
24    of this paragraph 12, and to be paid from funds
25    appropriated to the Department for its medical programs,
26    any uninsured person as defined by the Department in rules

 

 

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1    residing in Illinois who is younger than 65 years of age,
2    who has been screened for breast and cervical cancer in
3    accordance with standards and procedures adopted by the
4    Department of Public Health for screening, and who is
5    referred to the Department by the Department of Public
6    Health as being in need of treatment for breast or
7    cervical cancer is eligible for medical assistance
8    benefits that are consistent with the benefits provided to
9    those persons described in subparagraphs (1) and (2).
10    Medical assistance coverage for the persons who are
11    eligible under the preceding sentence is not dependent on
12    federal approval, but federal moneys may be used to pay
13    for services provided under that coverage upon federal
14    approval.
15        13. Subject to appropriation and to federal approval,
16    persons living with HIV/AIDS who are not otherwise
17    eligible under this Article and who qualify for services
18    covered under Section 5-5.04 as provided by the Illinois
19    Department by rule.
20        14. Subject to the availability of funds for this
21    purpose, the Department may provide coverage under this
22    Article to persons who reside in Illinois who are not
23    eligible under any of the preceding paragraphs and who
24    meet the income guidelines of paragraph 2(a) of this
25    Section and (i) have an application for asylum pending
26    before the federal Department of Homeland Security or on

 

 

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1    appeal before a court of competent jurisdiction and are
2    represented either by counsel or by an advocate accredited
3    by the federal Department of Homeland Security and
4    employed by a not-for-profit organization in regard to
5    that application or appeal, or (ii) are receiving services
6    through a federally funded torture treatment center.
7    Medical coverage under this paragraph 14 may be provided
8    for up to 24 continuous months from the initial
9    eligibility date so long as an individual continues to
10    satisfy the criteria of this paragraph 14. If an
11    individual has an appeal pending regarding an application
12    for asylum before the Department of Homeland Security,
13    eligibility under this paragraph 14 may be extended until
14    a final decision is rendered on the appeal. The Department
15    may adopt rules governing the implementation of this
16    paragraph 14.
17        15. Family Care Eligibility.
18            (a) On and after July 1, 2012, a parent or other
19        caretaker relative who is 19 years of age or older when
20        countable income is at or below 133% of the federal
21        poverty level. A person may not spend down to become
22        eligible under this paragraph 15.
23            (b) Eligibility shall be reviewed annually.
24            (c) (Blank).
25            (d) (Blank).
26            (e) (Blank).

 

 

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1            (f) (Blank).
2            (g) (Blank).
3            (h) (Blank).
4            (i) Following termination of an individual's
5        coverage under this paragraph 15, the individual must
6        be determined eligible before the person can be
7        re-enrolled.
8        16. Subject to appropriation, uninsured persons who
9    are not otherwise eligible under this Section who have
10    been certified and referred by the Department of Public
11    Health as having been screened and found to need
12    diagnostic evaluation or treatment, or both diagnostic
13    evaluation and treatment, for prostate or testicular
14    cancer. For the purposes of this paragraph 16, uninsured
15    persons are those who do not have creditable coverage, as
16    defined under the Health Insurance Portability and
17    Accountability Act, or have otherwise exhausted any
18    insurance benefits they may have had, for prostate or
19    testicular cancer diagnostic evaluation or treatment, or
20    both diagnostic evaluation and treatment. To be eligible,
21    a person must furnish a Social Security number. A person's
22    assets are exempt from consideration in determining
23    eligibility under this paragraph 16. Such persons shall be
24    eligible for medical assistance under this paragraph 16
25    for so long as they need treatment for the cancer. A person
26    shall be considered to need treatment if, in the opinion

 

 

10200SB0967sam002- 33 -LRB102 04880 CPF 26303 a

1    of the person's treating physician, the person requires
2    therapy directed toward cure or palliation of prostate or
3    testicular cancer, including recurrent metastatic cancer
4    that is a known or presumed complication of prostate or
5    testicular cancer and complications resulting from the
6    treatment modalities themselves. Persons who require only
7    routine monitoring services are not considered to need
8    treatment. "Medical assistance" under this paragraph 16
9    shall be identical to the benefits provided under the
10    State's approved plan under Title XIX of the Social
11    Security Act. Notwithstanding any other provision of law,
12    the Department (i) does not have a claim against the
13    estate of a deceased recipient of services under this
14    paragraph 16 and (ii) does not have a lien against any
15    homestead property or other legal or equitable real
16    property interest owned by a recipient of services under
17    this paragraph 16.
18        17. Persons who, pursuant to a waiver approved by the
19    Secretary of the U.S. Department of Health and Human
20    Services, are eligible for medical assistance under Title
21    XIX or XXI of the federal Social Security Act.
22    Notwithstanding any other provision of this Code and
23    consistent with the terms of the approved waiver, the
24    Illinois Department, may by rule:
25            (a) Limit the geographic areas in which the waiver
26        program operates.

 

 

10200SB0967sam002- 34 -LRB102 04880 CPF 26303 a

1            (b) Determine the scope, quantity, duration, and
2        quality, and the rate and method of reimbursement, of
3        the medical services to be provided, which may differ
4        from those for other classes of persons eligible for
5        assistance under this Article.
6            (c) Restrict the persons' freedom in choice of
7        providers.
8        18. Beginning January 1, 2014, persons aged 19 or
9    older, but younger than 65, who are not otherwise eligible
10    for medical assistance under this Section 5-2, who qualify
11    for medical assistance pursuant to 42 U.S.C.
12    1396a(a)(10)(A)(i)(VIII) and applicable federal
13    regulations, and who have income at or below 133% of the
14    federal poverty level plus 5% for the applicable family
15    size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
16    applicable federal regulations. Persons eligible for
17    medical assistance under this paragraph 18 shall receive
18    coverage for the Health Benefits Service Package as that
19    term is defined in subsection (m) of Section 5-1.1 of this
20    Code. If Illinois' federal medical assistance percentage
21    (FMAP) is reduced below 90% for persons eligible for
22    medical assistance under this paragraph 18, eligibility
23    under this paragraph 18 shall cease no later than the end
24    of the third month following the month in which the
25    reduction in FMAP takes effect.
26        19. Beginning January 1, 2014, as required under 42

 

 

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1    U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
2    and younger than age 26 who are not otherwise eligible for
3    medical assistance under paragraphs (1) through (17) of
4    this Section who (i) were in foster care under the
5    responsibility of the State on the date of attaining age
6    18 or on the date of attaining age 21 when a court has
7    continued wardship for good cause as provided in Section
8    2-31 of the Juvenile Court Act of 1987 and (ii) received
9    medical assistance under the Illinois Title XIX State Plan
10    or waiver of such plan while in foster care.
11        20. Beginning January 1, 2018, persons who are
12    foreign-born victims of human trafficking, torture, or
13    other serious crimes as defined in Section 2-19 of this
14    Code and their derivative family members if such persons:
15    (i) reside in Illinois; (ii) are not eligible under any of
16    the preceding paragraphs; (iii) meet the income guidelines
17    of subparagraph (a) of paragraph 2; and (iv) meet the
18    nonfinancial eligibility requirements of Sections 16-2,
19    16-3, and 16-5 of this Code. The Department may extend
20    medical assistance for persons who are foreign-born
21    victims of human trafficking, torture, or other serious
22    crimes whose medical assistance would be terminated
23    pursuant to subsection (b) of Section 16-5 if the
24    Department determines that the person, during the year of
25    initial eligibility (1) experienced a health crisis, (2)
26    has been unable, after reasonable attempts, to obtain

 

 

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1    necessary information from a third party, or (3) has other
2    extenuating circumstances that prevented the person from
3    completing his or her application for status. The
4    Department may adopt any rules necessary to implement the
5    provisions of this paragraph.
6        21. Persons who are not otherwise eligible for medical
7    assistance under this Section who may qualify for medical
8    assistance pursuant to 42 U.S.C.
9    1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
10    duration of any federal or State declared emergency due to
11    COVID-19. Medical assistance to persons eligible for
12    medical assistance solely pursuant to this paragraph 21
13    shall be limited to any in vitro diagnostic product (and
14    the administration of such product) described in 42 U.S.C.
15    1396d(a)(3)(B) on or after March 18, 2020, any visit
16    described in 42 U.S.C. 1396o(a)(2)(G), or any other
17    medical assistance that may be federally authorized for
18    this class of persons. The Department may also cover
19    treatment of COVID-19 for this class of persons, or any
20    similar category of uninsured individuals, to the extent
21    authorized under a federally approved 1115 Waiver or other
22    federal authority. Notwithstanding the provisions of
23    Section 1-11 of this Code, due to the nature of the
24    COVID-19 public health emergency, the Department may cover
25    and provide the medical assistance described in this
26    paragraph 21 to noncitizens who would otherwise meet the

 

 

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1    eligibility requirements for the class of persons
2    described in this paragraph 21 for the duration of the
3    State emergency period.
4    In implementing the provisions of Public Act 96-20, the
5Department is authorized to adopt only those rules necessary,
6including emergency rules. Nothing in Public Act 96-20 permits
7the Department to adopt rules or issue a decision that expands
8eligibility for the FamilyCare Program to a person whose
9income exceeds 185% of the Federal Poverty Level as determined
10from time to time by the U.S. Department of Health and Human
11Services, unless the Department is provided with express
12statutory authority.
13    The eligibility of any such person for medical assistance
14under this Article is not affected by the payment of any grant
15under the Senior Citizens and Persons with Disabilities
16Property Tax Relief Act or any distributions or items of
17income described under subparagraph (X) of paragraph (2) of
18subsection (a) of Section 203 of the Illinois Income Tax Act.
19    The Department shall by rule establish the amounts of
20assets to be disregarded in determining eligibility for
21medical assistance, which shall at a minimum equal the amounts
22to be disregarded under the Federal Supplemental Security
23Income Program. The amount of assets of a single person to be
24disregarded shall not be less than $2,000, and the amount of
25assets of a married couple to be disregarded shall not be less
26than $3,000.

 

 

10200SB0967sam002- 38 -LRB102 04880 CPF 26303 a

1    To the extent permitted under federal law, any person
2found guilty of a second violation of Article VIIIA shall be
3ineligible for medical assistance under this Article, as
4provided in Section 8A-8.
5    The eligibility of any person for medical assistance under
6this Article shall not be affected by the receipt by the person
7of donations or benefits from fundraisers held for the person
8in cases of serious illness, as long as neither the person nor
9members of the person's family have actual control over the
10donations or benefits or the disbursement of the donations or
11benefits.
12    Notwithstanding any other provision of this Code, if the
13United States Supreme Court holds Title II, Subtitle A,
14Section 2001(a) of Public Law 111-148 to be unconstitutional,
15or if a holding of Public Law 111-148 makes Medicaid
16eligibility allowed under Section 2001(a) inoperable, the
17State or a unit of local government shall be prohibited from
18enrolling individuals in the Medical Assistance Program as the
19result of federal approval of a State Medicaid waiver on or
20after June 14, 2012 (the effective date of Public Act 97-687)
21this amendatory Act of the 97th General Assembly, and any
22individuals enrolled in the Medical Assistance Program
23pursuant to eligibility permitted as a result of such a State
24Medicaid waiver shall become immediately ineligible.
25    Notwithstanding any other provision of this Code, if an
26Act of Congress that becomes a Public Law eliminates Section

 

 

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12001(a) of Public Law 111-148, the State or a unit of local
2government shall be prohibited from enrolling individuals in
3the Medical Assistance Program as the result of federal
4approval of a State Medicaid waiver on or after June 14, 2012
5(the effective date of Public Act 97-687) this amendatory Act
6of the 97th General Assembly, and any individuals enrolled in
7the Medical Assistance Program pursuant to eligibility
8permitted as a result of such a State Medicaid waiver shall
9become immediately ineligible.
10    Effective October 1, 2013, the determination of
11eligibility of persons who qualify under paragraphs 5, 6, 8,
1215, 17, and 18 of this Section shall comply with the
13requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
14regulations.
15    The Department of Healthcare and Family Services, the
16Department of Human Services, and the Illinois health
17insurance marketplace shall work cooperatively to assist
18persons who would otherwise lose health benefits as a result
19of changes made under Public Act 98-104 this amendatory Act of
20the 98th General Assembly to transition to other health
21insurance coverage.
22(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
23revised 8-24-20.)
 
24    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
25    Sec. 5-5. Medical services. The Illinois Department, by

 

 

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1rule, shall determine the quantity and quality of and the rate
2of reimbursement for the medical assistance for which payment
3will be authorized, and the medical services to be provided,
4which may include all or part of the following: (1) inpatient
5hospital services; (2) outpatient hospital services; (3) other
6laboratory and X-ray services; (4) skilled nursing home
7services; (5) physicians' services whether furnished in the
8office, the patient's home, a hospital, a skilled nursing
9home, or elsewhere; (6) medical care, or any other type of
10remedial care furnished by licensed practitioners; (7) home
11health care services; (8) private duty nursing service; (9)
12clinic services; (10) dental services, including prevention
13and treatment of periodontal disease and dental caries disease
14for pregnant individuals women, provided by an individual
15licensed to practice dentistry or dental surgery; for purposes
16of this item (10), "dental services" means diagnostic,
17preventive, or corrective procedures provided by or under the
18supervision of a dentist in the practice of his or her
19profession; (11) physical therapy and related services; (12)
20prescribed drugs, dentures, and prosthetic devices; and
21eyeglasses prescribed by a physician skilled in the diseases
22of the eye, or by an optometrist, whichever the person may
23select; (13) other diagnostic, screening, preventive, and
24rehabilitative services, including to ensure that the
25individual's need for intervention or treatment of mental
26disorders or substance use disorders or co-occurring mental

 

 

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1health and substance use disorders is determined using a
2uniform screening, assessment, and evaluation process
3inclusive of criteria, for children and adults; for purposes
4of this item (13), a uniform screening, assessment, and
5evaluation process refers to a process that includes an
6appropriate evaluation and, as warranted, a referral;
7"uniform" does not mean the use of a singular instrument,
8tool, or process that all must utilize; (14) transportation
9and such other expenses as may be necessary; (15) medical
10treatment of sexual assault survivors, as defined in Section
111a of the Sexual Assault Survivors Emergency Treatment Act,
12for injuries sustained as a result of the sexual assault,
13including examinations and laboratory tests to discover
14evidence which may be used in criminal proceedings arising
15from the sexual assault; (16) the diagnosis and treatment of
16sickle cell anemia; and (17) any other medical care, and any
17other type of remedial care recognized under the laws of this
18State. The term "any other type of remedial care" shall
19include nursing care and nursing home service for persons who
20rely on treatment by spiritual means alone through prayer for
21healing.
22    Notwithstanding any other provision of this Section, a
23comprehensive tobacco use cessation program that includes
24purchasing prescription drugs or prescription medical devices
25approved by the Food and Drug Administration shall be covered
26under the medical assistance program under this Article for

 

 

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

 

 

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

 

 

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

 

 

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1classify the medical services to be provided only in
2accordance with the classes of persons designated in Section
35-2.
4    The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11    The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for
14individuals women 35 years of age or older who are eligible for
15medical assistance under this Article, as follows:
16        (A) A baseline mammogram for individuals women 35 to
17    39 years of age.
18        (B) An annual mammogram for individuals women 40 years
19    of age or older.
20        (C) A mammogram at the age and intervals considered
21    medically necessary by the individual's woman's health
22    care provider for individuals women under 40 years of age
23    and having a family history of breast cancer, prior
24    personal history of breast cancer, positive genetic
25    testing, or other risk factors.
26        (D) A comprehensive ultrasound screening and MRI of an

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1form of a quality performance bonus to primary care providers
2who meet that goal.
3    The Department shall devise a means of case-managing or
4patient navigation for beneficiaries diagnosed with breast
5cancer. This program shall initially operate as a pilot
6program in areas of the State with the highest incidence of
7mortality related to breast cancer. At least one pilot program
8site shall be in the metropolitan Chicago area and at least one
9site shall be outside the metropolitan Chicago area. On or
10after July 1, 2016, the pilot program shall be expanded to
11include one site in western Illinois, one site in southern
12Illinois, one site in central Illinois, and 4 sites within
13metropolitan Chicago. An evaluation of the pilot program shall
14be carried out measuring health outcomes and cost of care for
15those served by the pilot program compared to similarly
16situated patients who are not served by the pilot program.
17    The Department shall require all networks of care to
18develop a means either internally or by contract with experts
19in navigation and community outreach to navigate cancer
20patients to comprehensive care in a timely fashion. The
21Department shall require all networks of care to include
22access for patients diagnosed with cancer to at least one
23academic commission on cancer-accredited cancer program as an
24in-network covered benefit.
25    On or after July 1, 2022, individuals who are otherwise
26eligible for medical assistance under this Article shall

 

 

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1receive coverage for perinatal depression screenings for the
212-month period beginning on the last day of their pregnancy.
3Medical assistance coverage under this paragraph shall be
4conditioned on the use of a screening instrument approved by
5the Department.
6    Any medical or health care provider shall immediately
7recommend, to any pregnant individual woman who is being
8provided prenatal services and is suspected of having a
9substance use disorder as defined in the Substance Use
10Disorder Act, referral to a local substance use disorder
11treatment program licensed by the Department of Human Services
12or to a licensed hospital which provides substance abuse
13treatment services. The Department of Healthcare and Family
14Services shall assure coverage for the cost of treatment of
15the drug abuse or addiction for pregnant recipients in
16accordance with the Illinois Medicaid Program in conjunction
17with the Department of Human Services.
18    All medical providers providing medical assistance to
19pregnant individuals women under this Code shall receive
20information from the Department on the availability of
21services under any program providing case management services
22for addicted individuals women, including information on
23appropriate referrals for other social services that may be
24needed by addicted individuals women in addition to treatment
25for addiction.
26    The Illinois Department, in cooperation with the

 

 

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1Departments of Human Services (as successor to the Department
2of Alcoholism and Substance Abuse) and Public Health, through
3a public awareness campaign, may provide information
4concerning treatment for alcoholism and drug abuse and
5addiction, prenatal health care, and other pertinent programs
6directed at reducing the number of drug-affected infants born
7to recipients of medical assistance.
8    Neither the Department of Healthcare and Family Services
9nor the Department of Human Services shall sanction the
10recipient solely on the basis of the recipient's her substance
11abuse.
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration
25projects in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by

 

 

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1rule, shall develop qualifications for sponsors of
2Partnerships. Nothing in this Section shall be construed to
3require that the sponsor organization be a medical
4organization.
5    The sponsor must negotiate formal written contracts with
6medical providers for physician services, inpatient and
7outpatient hospital care, home health services, treatment for
8alcoholism and substance abuse, and other services determined
9necessary by the Illinois Department by rule for delivery by
10Partnerships. Physician services must include prenatal and
11obstetrical care. The Illinois Department shall reimburse
12medical services delivered by Partnership providers to clients
13in target areas according to provisions of this Article and
14the Illinois Health Finance Reform Act, except that:
15        (1) Physicians participating in a Partnership and
16    providing certain services, which shall be determined by
17    the Illinois Department, to persons in areas covered by
18    the Partnership may receive an additional surcharge for
19    such services.
20        (2) The Department may elect to consider and negotiate
21    financial incentives to encourage the development of
22    Partnerships and the efficient delivery of medical care.
23        (3) Persons receiving medical services through
24    Partnerships may receive medical and case management
25    services above the level usually offered through the
26    medical assistance program.

 

 

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1    Medical providers shall be required to meet certain
2qualifications to participate in Partnerships to ensure the
3delivery of high quality medical services. These
4qualifications shall be determined by rule of the Illinois
5Department and may be higher than qualifications for
6participation in the medical assistance program. Partnership
7sponsors may prescribe reasonable additional qualifications
8for participation by medical providers, only with the prior
9written approval of the Illinois Department.
10    Nothing in this Section shall limit the free choice of
11practitioners, hospitals, and other providers of medical
12services by clients. In order to ensure patient freedom of
13choice, the Illinois Department shall immediately promulgate
14all rules and take all other necessary actions so that
15provided services may be accessed from therapeutically
16certified optometrists to the full extent of the Illinois
17Optometric Practice Act of 1987 without discriminating between
18service providers.
19    The Department shall apply for a waiver from the United
20States Health Care Financing Administration to allow for the
21implementation of Partnerships under this Section.
22    The Illinois Department shall require health care
23providers to maintain records that document the medical care
24and services provided to recipients of Medical Assistance
25under this Article. Such records must be retained for a period
26of not less than 6 years from the date of service or as

 

 

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1provided by applicable State law, whichever period is longer,
2except that if an audit is initiated within the required
3retention period then the records must be retained until the
4audit is completed and every exception is resolved. The
5Illinois Department shall require health care providers to
6make available, when authorized by the patient, in writing,
7the medical records in a timely fashion to other health care
8providers who are treating or serving persons eligible for
9Medical Assistance under this Article. All dispensers of
10medical services shall be required to maintain and retain
11business and professional records sufficient to fully and
12accurately document the nature, scope, details and receipt of
13the health care provided to persons eligible for medical
14assistance under this Code, in accordance with regulations
15promulgated by the Illinois Department. The rules and
16regulations shall require that proof of the receipt of
17prescription drugs, dentures, prosthetic devices and
18eyeglasses by eligible persons under this Section accompany
19each claim for reimbursement submitted by the dispenser of
20such medical services. No such claims for reimbursement shall
21be approved for payment by the Illinois Department without
22such proof of receipt, unless the Illinois Department shall
23have put into effect and shall be operating a system of
24post-payment audit and review which shall, on a sampling
25basis, be deemed adequate by the Illinois Department to assure
26that such drugs, dentures, prosthetic devices and eyeglasses

 

 

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1for which payment is being made are actually being received by
2eligible recipients. Within 90 days after September 16, 1984
3(the effective date of Public Act 83-1439), the Illinois
4Department shall establish a current list of acquisition costs
5for all prosthetic devices and any other items recognized as
6medical equipment and supplies reimbursable under this Article
7and shall update such list on a quarterly basis, except that
8the acquisition costs of all prescription drugs shall be
9updated no less frequently than every 30 days as required by
10Section 5-5.12.
11    Notwithstanding any other law to the contrary, the
12Illinois Department shall, within 365 days after July 22, 2013
13(the effective date of Public Act 98-104), establish
14procedures to permit skilled care facilities licensed under
15the Nursing Home Care Act to submit monthly billing claims for
16reimbursement purposes. Following development of these
17procedures, the Department shall, by July 1, 2016, test the
18viability of the new system and implement any necessary
19operational or structural changes to its information
20technology platforms in order to allow for the direct
21acceptance and payment of nursing home claims.
22    Notwithstanding any other law to the contrary, the
23Illinois Department shall, within 365 days after August 15,
242014 (the effective date of Public Act 98-963), establish
25procedures to permit ID/DD facilities licensed under the ID/DD
26Community Care Act and MC/DD facilities licensed under the

 

 

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1MC/DD Act to submit monthly billing claims for reimbursement
2purposes. Following development of these procedures, the
3Department shall have an additional 365 days to test the
4viability of the new system and to ensure that any necessary
5operational or structural changes to its information
6technology platforms are implemented.
7    The Illinois Department shall require all dispensers of
8medical services, other than an individual practitioner or
9group of practitioners, desiring to participate in the Medical
10Assistance program established under this Article to disclose
11all financial, beneficial, ownership, equity, surety or other
12interests in any and all firms, corporations, partnerships,
13associations, business enterprises, joint ventures, agencies,
14institutions or other legal entities providing any form of
15health care services in this State under this Article.
16    The Illinois Department may require that all dispensers of
17medical services desiring to participate in the medical
18assistance program established under this Article disclose,
19under such terms and conditions as the Illinois Department may
20by rule establish, all inquiries from clients and attorneys
21regarding medical bills paid by the Illinois Department, which
22inquiries could indicate potential existence of claims or
23liens for the Illinois Department.
24    Enrollment of a vendor shall be subject to a provisional
25period and shall be conditional for one year. During the
26period of conditional enrollment, the Department may terminate

 

 

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

 

 

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

 

 

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

 

 

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1payment under the medical assistance program, and the State
2shall have no liability for payment of those claims.
3    To the extent consistent with applicable information and
4privacy, security, and disclosure laws, State and federal
5agencies and departments shall provide the Illinois Department
6access to confidential and other information and data
7necessary to perform eligibility and payment verifications and
8other Illinois Department functions. This includes, but is not
9limited to: information pertaining to licensure;
10certification; earnings; immigration status; citizenship; wage
11reporting; unearned and earned income; pension income;
12employment; supplemental security income; social security
13numbers; National Provider Identifier (NPI) numbers; the
14National Practitioner Data Bank (NPDB); program and agency
15exclusions; taxpayer identification numbers; tax delinquency;
16corporate information; and death records.
17    The Illinois Department shall enter into agreements with
18State agencies and departments, and is authorized to enter
19into agreements with federal agencies and departments, under
20which such agencies and departments shall share data necessary
21for medical assistance program integrity functions and
22oversight. The Illinois Department shall develop, in
23cooperation with other State departments and agencies, and in
24compliance with applicable federal laws and regulations,
25appropriate and effective methods to share such data. At a
26minimum, and to the extent necessary to provide data sharing,

 

 

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

 

 

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

 

 

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

 

 

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1organizations.
2    The Department shall execute, relative to the nursing home
3prescreening project, written inter-agency agreements with the
4Department of Human Services and the Department on Aging, to
5effect the following: (i) intake procedures and common
6eligibility criteria for those persons who are receiving
7non-institutional services; and (ii) the establishment and
8development of non-institutional services in areas of the
9State where they are not currently available or are
10undeveloped; and (iii) notwithstanding any other provision of
11law, subject to federal approval, on and after July 1, 2012, an
12increase in the determination of need (DON) scores from 29 to
1337 for applicants for institutional and home and
14community-based long term care; if and only if federal
15approval is not granted, the Department may, in conjunction
16with other affected agencies, implement utilization controls
17or changes in benefit packages to effectuate a similar savings
18amount for this population; and (iv) no later than July 1,
192013, minimum level of care eligibility criteria for
20institutional and home and community-based long term care; and
21(v) no later than October 1, 2013, establish procedures to
22permit long term care providers access to eligibility scores
23for individuals with an admission date who are seeking or
24receiving services from the long term care provider. In order
25to select the minimum level of care eligibility criteria, the
26Governor shall establish a workgroup that includes affected

 

 

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1agency representatives and stakeholders representing the
2institutional and home and community-based long term care
3interests. This Section shall not restrict the Department from
4implementing lower level of care eligibility criteria for
5community-based services in circumstances where federal
6approval has been granted.
7    The Illinois Department shall develop and operate, in
8cooperation with other State Departments and agencies and in
9compliance with applicable federal laws and regulations,
10appropriate and effective systems of health care evaluation
11and programs for monitoring of utilization of health care
12services and facilities, as it affects persons eligible for
13medical assistance under this Code.
14    The Illinois Department shall report annually to the
15General Assembly, no later than the second Friday in April of
161979 and each year thereafter, in regard to:
17        (a) actual statistics and trends in utilization of
18    medical services by public aid recipients;
19        (b) actual statistics and trends in the provision of
20    the various medical services by medical vendors;
21        (c) current rate structures and proposed changes in
22    those rate structures for the various medical vendors; and
23        (d) efforts at utilization review and control by the
24    Illinois Department.
25    The period covered by each report shall be the 3 years
26ending on the June 30 prior to the report. The report shall

 

 

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1include suggested legislation for consideration by the General
2Assembly. The requirement for reporting to the General
3Assembly shall be satisfied by filing copies of the report as
4required by Section 3.1 of the General Assembly Organization
5Act, and filing such additional copies with the State
6Government Report Distribution Center for the General Assembly
7as is required under paragraph (t) of Section 7 of the State
8Library Act.
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    On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate
18of reimbursement for services or other payments in accordance
19with Section 5-5e.
20    Because kidney transplantation can be an appropriate,
21cost-effective alternative to renal dialysis when medically
22necessary and notwithstanding the provisions of Section 1-11
23of this Code, beginning October 1, 2014, the Department shall
24cover kidney transplantation for noncitizens with end-stage
25renal disease who are not eligible for comprehensive medical
26benefits, who meet the residency requirements of Section 5-3

 

 

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

 

 

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1medical assistance under this Article. As used in this
2Section, "opioid antagonist" means a drug that binds to opioid
3receptors and blocks or inhibits the effect of opioids acting
4on those receptors, including, but not limited to, naloxone
5hydrochloride or any other similarly acting drug approved by
6the U.S. Food and Drug Administration.
7    Upon federal approval, the Department shall provide
8coverage and reimbursement for all drugs that are approved for
9marketing by the federal Food and Drug Administration and that
10are recommended by the federal Public Health Service or the
11United States Centers for Disease Control and Prevention for
12pre-exposure prophylaxis and related pre-exposure prophylaxis
13services, including, but not limited to, HIV and sexually
14transmitted infection screening, treatment for sexually
15transmitted infections, medical monitoring, assorted labs, and
16counseling to reduce the likelihood of HIV infection among
17individuals who are not infected with HIV but who are at high
18risk of HIV infection.
19    A federally qualified health center, as defined in Section
201905(l)(2)(B) of the federal Social Security Act, shall be
21reimbursed by the Department in accordance with the federally
22qualified health center's encounter rate for services provided
23to medical assistance recipients that are performed by a
24dental hygienist, as defined under the Illinois Dental
25Practice Act, working under the general supervision of a
26dentist and employed by a federally qualified health center.

 

 

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1    Within 90 days after the effective date of this amendatory
2Act of the 102nd General Assembly, the Department shall seek
3federal approval of a State Plan amendment to expand coverage
4for family planning services that includes presumptive
5eligibility to individuals whose income is at or below 208% of
6the federal poverty level. Coverage under this Section shall
7be effective beginning on July 1, 2022.
8(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
9100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
106-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
11eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
12100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
131-1-20; revised 9-18-19.)
 
14    (305 ILCS 5/5-5.24)
15    Sec. 5-5.24. Prenatal and perinatal care. The Department
16of Healthcare and Family Services may provide reimbursement
17under this Article for all prenatal and perinatal health care
18services that are provided for the purpose of preventing
19low-birthweight infants, reducing the need for neonatal
20intensive care hospital services, and promoting perinatal and
21maternal health. These services may include comprehensive risk
22assessments for pregnant individuals women, individuals women
23with infants, and infants, lactation counseling, nutrition
24counseling, childbirth support, psychosocial counseling,
25treatment and prevention of periodontal disease, language

 

 

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1translation, nurse home visitation, and other support services
2that have been proven to improve birth and maternal health
3outcomes. The Department shall maximize the use of preventive
4prenatal and perinatal health care services consistent with
5federal statutes, rules, and regulations. The Department of
6Public Aid (now Department of Healthcare and Family Services)
7shall develop a plan for prenatal and perinatal preventive
8health care and shall present the plan to the General Assembly
9by January 1, 2004. On or before January 1, 2006 and every 2
10years thereafter, the Department shall report to the General
11Assembly concerning the effectiveness of prenatal and
12perinatal health care services reimbursed under this Section
13in preventing low-birthweight infants and reducing the need
14for neonatal intensive care hospital services. Each such
15report shall include an evaluation of how the ratio of
16expenditures for treating low-birthweight infants compared
17with the investment in promoting healthy births and infants in
18local community areas throughout Illinois relates to healthy
19infant development in those areas.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate
23of reimbursement for services or other payments in accordance
24with Section 5-5e.
25(Source: P.A. 97-689, eff. 6-14-12.)
 

 

 

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1    (305 ILCS 5/5-18.10 new)
2    Sec. 5-18.10. Reimbursement for postpartum visits.
3    (a) In this Section:
4    "Certified lactation counselor" means a health care
5professional in lactation counseling who has demonstrated the
6necessary skills, knowledge, and attitudes to provide clinical
7breastfeeding counseling and management support to families
8who are thinking about breastfeeding or who have questions or
9problems during the course of breastfeeding.
10    "Certified nurse midwife" means a person who exceeds the
11competencies for a midwife contained in the Essential
12Competencies for Midwifery Practice, published by the
13International Confederation of Midwives, and who qualifies as
14an advanced practice registered nurse.
15    "Community health worker" means a frontline public health
16worker who is a trusted member or has an unusually close
17understanding of the community served. This trusting
18relationship enables the community health worker to serve as a
19liaison, link, and intermediary between health and social
20services and the community to facilitate access to services
21and improve the quality and cultural competence of service
22delivery.
23    "International board-certified lactation consultant"
24means a health care professional who is certified by the
25International Board of Lactation Consultant Examiners and
26specializes in the clinical management of breastfeeding.

 

 

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1    "Medical caseworker" means a health care professional who
2assists in the planning, coordination, monitoring, and
3evaluation of medical services for a patient with emphasis on
4quality of care, continuity of services, and affordability.
5    "Perinatal doula" means a trained provider of regular and
6voluntary physical, emotional, and educational support, but
7not medical or midwife care, to pregnant and birthing persons
8before, during, and after childbirth, otherwise known as the
9perinatal period.
10    "Public health nurse" means a registered nurse who
11promotes and protects the health of populations using
12knowledge from nursing, social, and public health sciences.
13    (b) The Illinois Department shall establish a medical
14assistance program to cover a universal postpartum visit
15within the first 3 weeks after childbirth and a comprehensive
16visit within 4 to 12 weeks postpartum for persons who are
17otherwise eligible for medical assistance under this Article.
18In addition, postpartum care services rendered by perinatal
19doulas, certified lactation counselors, international
20board-certified lactation consultants, public health nurses,
21certified nurse midwives, community health workers, and
22medical caseworkers shall be covered under the medical
23assistance program.
 
24    Section 99. Effective date. This Act takes effect upon
25becoming law.".