State of Illinois
2023 and 2024


Introduced 2/6/2024, by Rep. Tracy Katz Muhl


305 ILCS 5/5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that certain self-measure blood pressure (SMBP) monitoring services involving patient education and training on the set-up and use of a SMBP devise and self-measurement data collection shall be covered and reimbursed under the medical assistance program.

LRB103 38245 KTG 68380 b





HB4759LRB103 38245 KTG 68380 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant individuals, provided by an individual licensed
22to practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or



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



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



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1eligible for assistance under this Article. The Department
2shall comply with all federal requirements necessary to obtain
3federal financial participation, as specified in 42 CFR
4433.15(b)(7), for telephone-based counseling services provided
5through the Illinois Tobacco Quitline, including, but not
6limited to: (i) entering into a memorandum of understanding or
7interagency agreement with the Department of Public Health, as
8administrator of the Illinois Tobacco Quitline; and (ii)
9developing a cost allocation plan for Medicaid-allowable
10Illinois Tobacco Quitline services in accordance with 45 CFR
1195.507. The Department shall submit the memorandum of
12understanding or interagency agreement, the cost allocation
13plan, and all other necessary documentation to the Centers for
14Medicare and Medicaid Services for review and approval.
15Coverage under this paragraph shall be contingent upon federal
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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



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1    On and after July 1, 2018, the Department of Healthcare
2and Family Services shall provide dental services to any adult
3who is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
12    On and after July 1, 2018, targeted dental services, as
13set forth in Exhibit D of the Consent Decree entered by the
14United States District Court for the Northern District of
15Illinois, Eastern Division, in the matter of Memisovski v.
16Maram, Case No. 92 C 1982, that are provided to adults under
17the medical assistance program shall be established at no less
18than the rates set forth in the "New Rate" column in Exhibit D
19of the Consent Decree for targeted dental services that are
20provided to persons under the age of 18 under the medical
21assistance program.
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally



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1enrolling as a participating provider in the medical
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
9    On and after January 1, 2022, the Department of Healthcare
10and Family Services shall administer and regulate a
11school-based dental program that allows for the out-of-office
12delivery of preventative dental services in a school setting
13to children under 19 years of age. The Department shall
14establish, by rule, guidelines for participation by providers
15and set requirements for follow-up referral care based on the
16requirements established in the Dental Office Reference Manual
17published by the Department that establishes the requirements
18for dentists participating in the All Kids Dental School
19Program. Every effort shall be made by the Department when
20developing the program requirements to consider the different
21geographic differences of both urban and rural areas of the
22State for initial treatment and necessary follow-up care. No
23provider shall be charged a fee by any unit of local government
24to participate in the school-based dental program administered
25by the Department. Nothing in this paragraph shall be
26construed to limit or preempt a home rule unit's or school



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



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



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



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1would require the State, pursuant to any provision of the
2Patient Protection and Affordable Care Act (Public Law
3111-148), including, but not limited to, 42 U.S.C.
418031(d)(3)(B) or any successor provision, to defray the cost
5of any coverage for breast tomosynthesis outlined in this
6paragraph, then the requirement that an insurer cover breast
7tomosynthesis is inoperative other than any such coverage
8authorized under Section 1902 of the Social Security Act, 42
9U.S.C. 1396a, and the State shall not assume any obligation
10for the cost of coverage for breast tomosynthesis set forth in
11this paragraph.
12    On and after January 1, 2016, the Department shall ensure
13that all networks of care for adult clients of the Department
14include access to at least one breast imaging Center of
15Imaging Excellence as certified by the American College of
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall
19be reimbursed for screening and diagnostic mammography at the
20same rate as the Medicare program's rates, including the
21increased reimbursement for digital mammography and, after
22January 1, 2023 (the effective date of Public Act 102-1018),
23breast tomosynthesis.
24    The Department shall convene an expert panel including
25representatives of hospitals, free-standing mammography
26facilities, and doctors, including radiologists, to establish



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



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1reminders and shall establish a methodology for evaluating
2their effectiveness and modifying the methodology based on the
4    The Department shall establish a performance goal for
5primary care providers with respect to their female patients
6over age 40 receiving an annual mammogram. This performance
7goal shall be used to provide additional reimbursement in the
8form of a quality performance bonus to primary care providers
9who meet that goal.
10    The Department shall devise a means of case-managing or
11patient navigation for beneficiaries diagnosed with breast
12cancer. This program shall initially operate as a pilot
13program in areas of the State with the highest incidence of
14mortality related to breast cancer. At least one pilot program
15site shall be in the metropolitan Chicago area and at least one
16site shall be outside the metropolitan Chicago area. On or
17after July 1, 2016, the pilot program shall be expanded to
18include one site in western Illinois, one site in southern
19Illinois, one site in central Illinois, and 4 sites within
20metropolitan Chicago. An evaluation of the pilot program shall
21be carried out measuring health outcomes and cost of care for
22those served by the pilot program compared to similarly
23situated patients who are not served by the pilot program.
24    The Department shall require all networks of care to
25develop a means either internally or by contract with experts
26in navigation and community outreach to navigate cancer



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1patients to comprehensive care in a timely fashion. The
2Department shall require all networks of care to include
3access for patients diagnosed with cancer to at least one
4academic commission on cancer-accredited cancer program as an
5in-network covered benefit.
6    The Department shall provide coverage and reimbursement
7for a human papillomavirus (HPV) vaccine that is approved for
8marketing by the federal Food and Drug Administration for all
9persons between the ages of 9 and 45. Subject to federal
10approval, the Department shall provide coverage and
11reimbursement for a human papillomavirus (HPV) vaccine for
12persons of the age of 46 and above who have been diagnosed with
13cervical dysplasia with a high risk of recurrence or
14progression. The Department shall disallow any
15preauthorization requirements for the administration of the
16human papillomavirus (HPV) vaccine.
17    On or after July 1, 2022, individuals who are otherwise
18eligible for medical assistance under this Article shall
19receive coverage for perinatal depression screenings for the
2012-month period beginning on the last day of their pregnancy.
21Medical assistance coverage under this paragraph shall be
22conditioned on the use of a screening instrument approved by
23the Department.
24    Any medical or health care provider shall immediately
25recommend, to any pregnant individual who is being provided
26prenatal services and is suspected of having a substance use



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1disorder as defined in the Substance Use Disorder Act,
2referral to a local substance use disorder treatment program
3licensed by the Department of Human Services or to a licensed
4hospital which provides substance abuse treatment services.
5The Department of Healthcare and Family Services shall assure
6coverage for the cost of treatment of the drug abuse or
7addiction for pregnant recipients in accordance with the
8Illinois Medicaid Program in conjunction with the Department
9of Human Services.
10    All medical providers providing medical assistance to
11pregnant individuals under this Code shall receive information
12from the Department on the availability of services under any
13program providing case management services for addicted
14individuals, including information on appropriate referrals
15for other social services that may be needed by addicted
16individuals in addition to treatment for addiction.
17    The Illinois Department, in cooperation with the
18Departments of Human Services (as successor to the Department
19of Alcoholism and Substance Abuse) and Public Health, through
20a public awareness campaign, may provide information
21concerning treatment for alcoholism and drug abuse and
22addiction, prenatal health care, and other pertinent programs
23directed at reducing the number of drug-affected infants born
24to recipients of medical assistance.
25    Neither the Department of Healthcare and Family Services
26nor the Department of Human Services shall sanction the



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1recipient solely on the basis of the recipient's substance
3    The Illinois Department shall establish such regulations
4governing the dispensing of health services under this Article
5as it shall deem appropriate. The Department should seek the
6advice of formal professional advisory committees appointed by
7the Director of the Illinois Department for the purpose of
8providing regular advice on policy and administrative matters,
9information dissemination and educational activities for
10medical and health care providers, and consistency in
11procedures to the Illinois Department.
12    The Illinois Department may develop and contract with
13Partnerships of medical providers to arrange medical services
14for persons eligible under Section 5-2 of this Code.
15Implementation of this Section may be by demonstration
16projects in certain geographic areas. The Partnership shall be
17represented by a sponsor organization. The Department, by
18rule, shall develop qualifications for sponsors of
19Partnerships. Nothing in this Section shall be construed to
20require that the sponsor organization be a medical
22    The sponsor must negotiate formal written contracts with
23medical providers for physician services, inpatient and
24outpatient hospital care, home health services, treatment for
25alcoholism and substance abuse, and other services determined
26necessary by the Illinois Department by rule for delivery by



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



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



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



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1Section 5-5.12.
2    Notwithstanding any other law to the contrary, the
3Illinois Department shall, within 365 days after July 22, 2013
4(the effective date of Public Act 98-104), establish
5procedures to permit skilled care facilities licensed under
6the Nursing Home Care Act to submit monthly billing claims for
7reimbursement purposes. Following development of these
8procedures, the Department shall, by July 1, 2016, test the
9viability of the new system and implement any necessary
10operational or structural changes to its information
11technology platforms in order to allow for the direct
12acceptance and payment of nursing home claims.
13    Notwithstanding any other law to the contrary, the
14Illinois Department shall, within 365 days after August 15,
152014 (the effective date of Public Act 98-963), establish
16procedures to permit ID/DD facilities licensed under the ID/DD
17Community Care Act and MC/DD facilities licensed under the
18MC/DD Act to submit monthly billing claims for reimbursement
19purposes. Following development of these procedures, the
20Department shall have an additional 365 days to test the
21viability of the new system and to ensure that any necessary
22operational or structural changes to its information
23technology platforms are implemented.
24    The Illinois Department shall require all dispensers of
25medical services, other than an individual practitioner or
26group of practitioners, desiring to participate in the Medical



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



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1    Prior to enrollment and during the conditional enrollment
2period in the medical assistance program, all vendors shall be
3subject to enhanced oversight, screening, and review based on
4the risk of fraud, waste, and abuse that is posed by the
5category of risk of the vendor. The Illinois Department shall
6establish the procedures for oversight, screening, and review,
7which may include, but need not be limited to: criminal and
8financial background checks; fingerprinting; license,
9certification, and authorization verifications; unscheduled or
10unannounced site visits; database checks; prepayment audit
11reviews; audits; payment caps; payment suspensions; and other
12screening as required by federal or State law.
13    The Department shall define or specify the following: (i)
14by provider notice, the "category of risk of the vendor" for
15each type of vendor, which shall take into account the level of
16screening applicable to a particular category of vendor under
17federal law and regulations; (ii) by rule or provider notice,
18the maximum length of the conditional enrollment period for
19each category of risk of the vendor; and (iii) by rule, the
20hearing rights, if any, afforded to a vendor in each category
21of risk of the vendor that is terminated or disenrolled during
22the conditional enrollment period.
23    To be eligible for payment consideration, a vendor's
24payment claim or bill, either as an initial claim or as a
25resubmitted claim following prior rejection, must be received
26by the Illinois Department, or its fiscal intermediary, no



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1later than 180 days after the latest date on the claim on which
2medical goods or services were provided, with the following
4        (1) In the case of a provider whose enrollment is in
5    process by the Illinois Department, the 180-day period
6    shall not begin until the date on the written notice from
7    the Illinois Department that the provider enrollment is
8    complete.
9        (2) In the case of errors attributable to the Illinois
10    Department or any of its claims processing intermediaries
11    which result in an inability to receive, process, or
12    adjudicate a claim, the 180-day period shall not begin
13    until the provider has been notified of the error.
14        (3) In the case of a provider for whom the Illinois
15    Department initiates the monthly billing process.
16        (4) In the case of a provider operated by a unit of
17    local government with a population exceeding 3,000,000
18    when local government funds finance federal participation
19    for claims payments.
20    For claims for services rendered during a period for which
21a recipient received retroactive eligibility, claims must be
22filed within 180 days after the Department determines the
23applicant is eligible. For claims for which the Illinois
24Department is not the primary payer, claims must be submitted
25to the Illinois Department within 180 days after the final
26adjudication by the primary payer.



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1    In the case of long term care facilities, within 120
2calendar days of receipt by the facility of required
3prescreening information, new admissions with associated
4admission documents shall be submitted through the Medical
5Electronic Data Interchange (MEDI) or the Recipient
6Eligibility Verification (REV) System or shall be submitted
7directly to the Department of Human Services using required
8admission forms. Effective September 1, 2014, admission
9documents, including all prescreening information, must be
10submitted through MEDI or REV. Confirmation numbers assigned
11to an accepted transaction shall be retained by a facility to
12verify timely submittal. Once an admission transaction has
13been completed, all resubmitted claims following prior
14rejection are subject to receipt no later than 180 days after
15the admission transaction has been completed.
16    Claims that are not submitted and received in compliance
17with the foregoing requirements shall not be eligible for
18payment under the medical assistance program, and the State
19shall have no liability for payment of those claims.
20    To the extent consistent with applicable information and
21privacy, security, and disclosure laws, State and federal
22agencies and departments shall provide the Illinois Department
23access to confidential and other information and data
24necessary to perform eligibility and payment verifications and
25other Illinois Department functions. This includes, but is not
26limited to: information pertaining to licensure;



HB4759- 25 -LRB103 38245 KTG 68380 b

1certification; earnings; immigration status; citizenship; wage
2reporting; unearned and earned income; pension income;
3employment; supplemental security income; social security
4numbers; National Provider Identifier (NPI) numbers; the
5National Practitioner Data Bank (NPDB); program and agency
6exclusions; taxpayer identification numbers; tax delinquency;
7corporate information; and death records.
8    The Illinois Department shall enter into agreements with
9State agencies and departments, and is authorized to enter
10into agreements with federal agencies and departments, under
11which such agencies and departments shall share data necessary
12for medical assistance program integrity functions and
13oversight. The Illinois Department shall develop, in
14cooperation with other State departments and agencies, and in
15compliance with applicable federal laws and regulations,
16appropriate and effective methods to share such data. At a
17minimum, and to the extent necessary to provide data sharing,
18the Illinois Department shall enter into agreements with State
19agencies and departments, and is authorized to enter into
20agreements with federal agencies and departments, including,
21but not limited to: the Secretary of State; the Department of
22Revenue; the Department of Public Health; the Department of
23Human Services; and the Department of Financial and
24Professional Regulation.
25    Beginning in fiscal year 2013, the Illinois Department
26shall set forth a request for information to identify the



HB4759- 26 -LRB103 38245 KTG 68380 b

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



HB4759- 27 -LRB103 38245 KTG 68380 b

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



HB4759- 28 -LRB103 38245 KTG 68380 b

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



HB4759- 29 -LRB103 38245 KTG 68380 b

1undeveloped; and (iii) notwithstanding any other provision of
2law, subject to federal approval, on and after July 1, 2012, an
3increase in the determination of need (DON) scores from 29 to
437 for applicants for institutional and home and
5community-based long term care; if and only if federal
6approval is not granted, the Department may, in conjunction
7with other affected agencies, implement utilization controls
8or changes in benefit packages to effectuate a similar savings
9amount for this population; and (iv) no later than July 1,
102013, minimum level of care eligibility criteria for
11institutional and home and community-based long term care; and
12(v) no later than October 1, 2013, establish procedures to
13permit long term care providers access to eligibility scores
14for individuals with an admission date who are seeking or
15receiving services from the long term care provider. In order
16to select the minimum level of care eligibility criteria, the
17Governor shall establish a workgroup that includes affected
18agency representatives and stakeholders representing the
19institutional and home and community-based long term care
20interests. This Section shall not restrict the Department from
21implementing lower level of care eligibility criteria for
22community-based services in circumstances where federal
23approval has been granted.
24    The Illinois Department shall develop and operate, in
25cooperation with other State Departments and agencies and in
26compliance with applicable federal laws and regulations,



HB4759- 30 -LRB103 38245 KTG 68380 b

1appropriate and effective systems of health care evaluation
2and programs for monitoring of utilization of health care
3services and facilities, as it affects persons eligible for
4medical assistance under this Code.
5    The Illinois Department shall report annually to the
6General Assembly, no later than the second Friday in April of
71979 and each year thereafter, in regard to:
8        (a) actual statistics and trends in utilization of
9    medical services by public aid recipients;
10        (b) actual statistics and trends in the provision of
11    the various medical services by medical vendors;
12        (c) current rate structures and proposed changes in
13    those rate structures for the various medical vendors; and
14        (d) efforts at utilization review and control by the
15    Illinois Department.
16    The period covered by each report shall be the 3 years
17ending on the June 30 prior to the report. The report shall
18include suggested legislation for consideration by the General
19Assembly. The requirement for reporting to the General
20Assembly shall be satisfied by filing copies of the report as
21required by Section 3.1 of the General Assembly Organization
22Act, and filing such additional copies with the State
23Government Report Distribution Center for the General Assembly
24as is required under paragraph (t) of Section 7 of the State
25Library Act.
26    Rulemaking authority to implement Public Act 95-1045, if



HB4759- 31 -LRB103 38245 KTG 68380 b

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    On and after July 1, 2012, the Department shall reduce any
7rate of reimbursement for services or other payments or alter
8any methodologies authorized by this Code to reduce any rate
9of reimbursement for services or other payments in accordance
10with Section 5-5e.
11    Because kidney transplantation can be an appropriate,
12cost-effective alternative to renal dialysis when medically
13necessary and notwithstanding the provisions of Section 1-11
14of this Code, beginning October 1, 2014, the Department shall
15cover kidney transplantation for noncitizens with end-stage
16renal disease who are not eligible for comprehensive medical
17benefits, who meet the residency requirements of Section 5-3
18of this Code, and who would otherwise meet the financial
19requirements of the appropriate class of eligible persons
20under Section 5-2 of this Code. To qualify for coverage of
21kidney transplantation, such person must be receiving
22emergency renal dialysis services covered by the Department.
23Providers under this Section shall be prior approved and
24certified by the Department to perform kidney transplantation
25and the services under this Section shall be limited to
26services associated with kidney transplantation.



HB4759- 32 -LRB103 38245 KTG 68380 b

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



HB4759- 33 -LRB103 38245 KTG 68380 b

1    Upon federal approval, the Department shall provide
2coverage and reimbursement for all drugs that are approved for
3marketing by the federal Food and Drug Administration and that
4are recommended by the federal Public Health Service or the
5United States Centers for Disease Control and Prevention for
6pre-exposure prophylaxis and related pre-exposure prophylaxis
7services, including, but not limited to, HIV and sexually
8transmitted infection screening, treatment for sexually
9transmitted infections, medical monitoring, assorted labs, and
10counseling to reduce the likelihood of HIV infection among
11individuals who are not infected with HIV but who are at high
12risk of HIV infection.
13    A federally qualified health center, as defined in Section
141905(l)(2)(B) of the federal Social Security Act, shall be
15reimbursed by the Department in accordance with the federally
16qualified health center's encounter rate for services provided
17to medical assistance recipients that are performed by a
18dental hygienist, as defined under the Illinois Dental
19Practice Act, working under the general supervision of a
20dentist and employed by a federally qualified health center.
21    Within 90 days after October 8, 2021 (the effective date
22of Public Act 102-665), the Department shall seek federal
23approval of a State Plan amendment to expand coverage for
24family planning services that includes presumptive eligibility
25to individuals whose income is at or below 208% of the federal
26poverty level. Coverage under this Section shall be effective



HB4759- 34 -LRB103 38245 KTG 68380 b

1beginning no later than December 1, 2022.
2    Subject to approval by the federal Centers for Medicare
3and Medicaid Services of a Title XIX State Plan amendment
4electing the Program of All-Inclusive Care for the Elderly
5(PACE) as a State Medicaid option, as provided for by Subtitle
6I (commencing with Section 4801) of Title IV of the Balanced
7Budget Act of 1997 (Public Law 105-33) and Part 460
8(commencing with Section 460.2) of Subchapter E of Title 42 of
9the Code of Federal Regulations, PACE program services shall
10become a covered benefit of the medical assistance program,
11subject to criteria established in accordance with all
12applicable laws.
13    Notwithstanding any other provision of this Code,
14community-based pediatric palliative care from a trained
15interdisciplinary team shall be covered under the medical
16assistance program as provided in Section 15 of the Pediatric
17Palliative Care Act.
18    Notwithstanding any other provision of this Code, within
1912 months after June 2, 2022 (the effective date of Public Act
20102-1037) and subject to federal approval, acupuncture
21services performed by an acupuncturist licensed under the
22Acupuncture Practice Act who is acting within the scope of his
23or her license shall be covered under the medical assistance
24program. The Department shall apply for any federal waiver or
25State Plan amendment, if required, to implement this
26paragraph. The Department may adopt any rules, including



HB4759- 35 -LRB103 38245 KTG 68380 b

1standards and criteria, necessary to implement this paragraph.
2    Notwithstanding any other provision of this Code, the
3medical assistance program shall, subject to appropriation and
4federal approval, reimburse hospitals for costs associated
5with a newborn screening test for the presence of
6metachromatic leukodystrophy, as required under the Newborn
7Metabolic Screening Act, at a rate not less than the fee
8charged by the Department of Public Health. The Department
9shall seek federal approval before the implementation of the
10newborn screening test fees by the Department of Public
12    Notwithstanding any other provision of this Code,
13beginning on January 1, 2024, subject to federal approval,
14cognitive assessment and care planning services provided to a
15person who experiences signs or symptoms of cognitive
16impairment, as defined by the Diagnostic and Statistical
17Manual of Mental Disorders, Fifth Edition, shall be covered
18under the medical assistance program for persons who are
19otherwise eligible for medical assistance under this Article.
20    Notwithstanding any other provision of this Code,
21medically necessary reconstructive services that are intended
22to restore physical appearance shall be covered under the
23medical assistance program for persons who are otherwise
24eligible for medical assistance under this Article. As used in
25this paragraph, "reconstructive services" means treatments
26performed on structures of the body damaged by trauma to



HB4759- 36 -LRB103 38245 KTG 68380 b

1restore physical appearance.
2    Notwithstanding any other provision of this Code, the
3following CPT codes and self-measure blood pressure monitoring
4services shall be covered and reimbursed under the medical
5assistance program for persons who are otherwise eligible for
6medical assistance under this Article:
7        (1) CPT code 99473: for patient education and training
8    services on the set-up and use of a self-measure blood
9    pressure measurement devise validated for clinical
10    accuracy and device calibration; and
11        (2) CPT code 99474: for separate self-measurements of
12    2 readings and the collection of data reports by the
13    patient or caregiver to the healthcare provider in order
14    to communicate blood pressure readings and create or
15    modify treatment plans.
16    As used in this paragraph, "CPT code" means the medical
17billing code set contained in the most recent version of the
18Current Procedural Terminology code book published by the
19American Medical Association.
20(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
21102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2255, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
23eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
24102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
255-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
26102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.



HB4759- 37 -LRB103 38245 KTG 68380 b

11-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
2103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
31-1-24; revised 12-15-23.)