Illinois General Assembly - Full Text of SB0067
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Full Text of SB0067  103rd General Assembly


Sen. Laura Fine

Filed: 3/24/2023





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2    AMENDMENT NO. ______. Amend Senate Bill 67 on page 3,
3immediately below line 4, by inserting the following:
4    "Section 10. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 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



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



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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the
3sexual assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; (16.5) services performed by
7a chiropractic physician licensed under the Medical Practice
8Act of 1987 and acting within the scope of his or her license,
9including, but not limited to, chiropractic manipulative
10treatment; and (17) any other medical care, and any other type
11of remedial care recognized under the laws of this State. The
12term "any other type of remedial care" shall include nursing
13care and nursing home service for persons who rely on
14treatment by spiritual means alone through prayer for healing.
15    Notwithstanding any other provision of this Section, a
16comprehensive tobacco use cessation program that includes
17purchasing prescription drugs or prescription medical devices
18approved by the Food and Drug Administration shall be covered
19under the medical assistance program under this Article for
20persons who are otherwise eligible for assistance under this
22    Notwithstanding any other provision of this Code,
23reproductive health care that is otherwise legal in Illinois
24shall be covered under the medical assistance program for
25persons who are otherwise eligible for medical assistance
26under this Article.



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1    Notwithstanding any other provision of this Section, all
2tobacco cessation medications approved by the United States
3Food and Drug Administration and all individual and group
4tobacco cessation counseling services and telephone-based
5counseling services and tobacco cessation medications provided
6through the Illinois Tobacco Quitline shall be covered under
7the medical assistance program for persons who are otherwise
8eligible for assistance under this Article. The Department
9shall comply with all federal requirements necessary to obtain
10federal financial participation, as specified in 42 CFR
11433.15(b)(7), for telephone-based counseling services provided
12through the Illinois Tobacco Quitline, including, but not
13limited to: (i) entering into a memorandum of understanding or
14interagency agreement with the Department of Public Health, as
15administrator of the Illinois Tobacco Quitline; and (ii)
16developing a cost allocation plan for Medicaid-allowable
17Illinois Tobacco Quitline services in accordance with 45 CFR
1895.507. The Department shall submit the memorandum of
19understanding or interagency agreement, the cost allocation
20plan, and all other necessary documentation to the Centers for
21Medicare and Medicaid Services for review and approval.
22Coverage under this paragraph shall be contingent upon federal
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a



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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured
14under this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare
24and Family Services may provide the following services to
25persons eligible for assistance under this Article who are
26participating in education, training or employment programs



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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in
6    the diseases of the eye, or by an optometrist, whichever
7    the person may select.
8    On and after July 1, 2018, the Department of Healthcare
9and Family Services shall provide dental services to any adult
10who is otherwise eligible for assistance under the medical
11assistance program. As used in this paragraph, "dental
12services" means diagnostic, preventative, restorative, or
13corrective procedures, including procedures and services for
14the prevention and treatment of periodontal disease and dental
15caries disease, provided by an individual who is licensed to
16practice dentistry or dental surgery or who is under the
17supervision of a dentist in the practice of his or her
19    On and after July 1, 2018, targeted dental services, as
20set forth in Exhibit D of the Consent Decree entered by the
21United States District Court for the Northern District of
22Illinois, Eastern Division, in the matter of Memisovski v.
23Maram, Case No. 92 C 1982, that are provided to adults under
24the medical assistance program shall be established at no less
25than the rates set forth in the "New Rate" column in Exhibit D
26of the Consent Decree for targeted dental services that are



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1provided to persons under the age of 18 under the medical
2assistance program.
3    Notwithstanding any other provision of this Code and
4subject to federal approval, the Department may adopt rules to
5allow a dentist who is volunteering his or her service at no
6cost to render dental services through an enrolled
7not-for-profit health clinic without the dentist personally
8enrolling as a participating provider in the medical
9assistance program. A not-for-profit health clinic shall
10include a public health clinic or Federally Qualified Health
11Center or other enrolled provider, as determined by the
12Department, through which dental services covered under this
13Section are performed. The Department shall establish a
14process for payment of claims for reimbursement for covered
15dental services rendered under this provision.
16    On and after January 1, 2022, the Department of Healthcare
17and Family Services shall administer and regulate a
18school-based dental program that allows for the out-of-office
19delivery of preventative dental services in a school setting
20to children under 19 years of age. The Department shall
21establish, by rule, guidelines for participation by providers
22and set requirements for follow-up referral care based on the
23requirements established in the Dental Office Reference Manual
24published by the Department that establishes the requirements
25for dentists participating in the All Kids Dental School
26Program. Every effort shall be made by the Department when



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1developing the program requirements to consider the different
2geographic differences of both urban and rural areas of the
3State for initial treatment and necessary follow-up care. No
4provider shall be charged a fee by any unit of local government
5to participate in the school-based dental program administered
6by the Department. Nothing in this paragraph shall be
7construed to limit or preempt a home rule unit's or school
8district's authority to establish, change, or administer a
9school-based dental program in addition to, or independent of,
10the school-based dental program administered by the
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in
14accordance with the classes of persons designated in Section
16    The Department of Healthcare and Family Services must
17provide coverage and reimbursement for amino acid-based
18elemental formulas, regardless of delivery method, for the
19diagnosis and treatment of (i) eosinophilic disorders and (ii)
20short bowel syndrome when the prescribing physician has issued
21a written order stating that the amino acid-based elemental
22formula is medically necessary.
23    The Illinois Department shall authorize the provision of,
24and shall authorize payment for, screening by low-dose
25mammography for the presence of occult breast cancer for
26individuals 35 years of age or older who are eligible for



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1medical assistance under this Article, as follows:
2        (A) A baseline mammogram for individuals 35 to 39
3    years of age.
4        (B) An annual mammogram for individuals 40 years of
5    age or older.
6        (C) A mammogram at the age and intervals considered
7    medically necessary by the individual's health care
8    provider for individuals under 40 years of age and having
9    a family history of breast cancer, prior personal history
10    of breast cancer, positive genetic testing, or other risk
11    factors.
12        (D) A comprehensive ultrasound screening and MRI of an
13    entire breast or breasts if a mammogram demonstrates
14    heterogeneous or dense breast tissue or when medically
15    necessary as determined by a physician licensed to
16    practice medicine in all of its branches.
17        (E) A screening MRI when medically necessary, as
18    determined by a physician licensed to practice medicine in
19    all of its branches.
20        (F) A diagnostic mammogram when medically necessary,
21    as determined by a physician licensed to practice medicine
22    in all its branches, advanced practice registered nurse,
23    or physician assistant.
24    The Department shall not impose a deductible, coinsurance,
25copayment, or any other cost-sharing requirement on the
26coverage provided under this paragraph; except that this



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1sentence does not apply to coverage of diagnostic mammograms
2to the extent such coverage would disqualify a high-deductible
3health plan from eligibility for a health savings account
4pursuant to Section 223 of the Internal Revenue Code (26
5U.S.C. 223).
6    All screenings shall include a physical breast exam,
7instruction on self-examination and information regarding the
8frequency of self-examination and its value as a preventative
10     For purposes of this Section:
11    "Diagnostic mammogram" means a mammogram obtained using
12diagnostic mammography.
13    "Diagnostic mammography" means a method of screening that
14is designed to evaluate an abnormality in a breast, including
15an abnormality seen or suspected on a screening mammogram or a
16subjective or objective abnormality otherwise detected in the
18    "Low-dose mammography" means the x-ray examination of the
19breast using equipment dedicated specifically for mammography,
20including the x-ray tube, filter, compression device, and
21image receptor, with an average radiation exposure delivery of
22less than one rad per breast for 2 views of an average size
23breast. The term also includes digital mammography and
24includes breast tomosynthesis.
25    "Breast tomosynthesis" means a radiologic procedure that
26involves the acquisition of projection images over the



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1stationary breast to produce cross-sectional digital
2three-dimensional images of the breast.
3    If, at any time, the Secretary of the United States
4Department of Health and Human Services, or its successor
5agency, promulgates rules or regulations to be published in
6the Federal Register or publishes a comment in the Federal
7Register or issues an opinion, guidance, or other action that
8would require the State, pursuant to any provision of the
9Patient Protection and Affordable Care Act (Public Law
10111-148), including, but not limited to, 42 U.S.C.
1118031(d)(3)(B) or any successor provision, to defray the cost
12of any coverage for breast tomosynthesis outlined in this
13paragraph, then the requirement that an insurer cover breast
14tomosynthesis is inoperative other than any such coverage
15authorized under Section 1902 of the Social Security Act, 42
16U.S.C. 1396a, and the State shall not assume any obligation
17for the cost of coverage for breast tomosynthesis set forth in
18this paragraph.
19    On and after January 1, 2016, the Department shall ensure
20that all networks of care for adult clients of the Department
21include access to at least one breast imaging Center of
22Imaging Excellence as certified by the American College of
24    On and after January 1, 2012, providers participating in a
25quality improvement program approved by the Department shall
26be reimbursed for screening and diagnostic mammography at the



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1same rate as the Medicare program's rates, including the
2increased reimbursement for digital mammography and, after
3January 1, 2023 (the effective date of Public Act 102-1018)
4this amendatory Act of the 102nd General Assembly, breast
6    The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10    On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16    The Department shall convene an expert panel, including
17representatives of hospitals, free-standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the



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



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1Illinois, one site in central Illinois, and 4 sites within
2metropolitan Chicago. An evaluation of the pilot program shall
3be carried out measuring health outcomes and cost of care for
4those served by the pilot program compared to similarly
5situated patients who are not served by the pilot program.
6    The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include
11access for patients diagnosed with cancer to at least one
12academic commission on cancer-accredited cancer program as an
13in-network covered benefit.
14    The Department shall provide coverage and reimbursement
15for a human papillomavirus (HPV) vaccine that is approved for
16marketing by the federal Food and Drug Administration for all
17persons between the ages of 9 and 45 and persons of the age of
1846 and above who have been diagnosed with cervical dysplasia
19with a high risk of recurrence or progression. The Department
20shall disallow any preauthorization requirements for the
21administration of the human papillomavirus (HPV) vaccine.
22    On or after July 1, 2022, individuals who are otherwise
23eligible for medical assistance under this Article shall
24receive coverage for perinatal depression screenings for the
2512-month period beginning on the last day of their pregnancy.
26Medical assistance coverage under this paragraph shall be



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



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



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



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



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



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1for all prosthetic devices and any other items recognized as
2medical equipment and supplies reimbursable under this Article
3and shall update such list on a quarterly basis, except that
4the acquisition costs of all prescription drugs shall be
5updated no less frequently than every 30 days as required by
6Section 5-5.12.
7    Notwithstanding any other law to the contrary, the
8Illinois Department shall, within 365 days after July 22, 2013
9(the effective date of Public Act 98-104), establish
10procedures to permit skilled care facilities licensed under
11the Nursing Home Care Act to submit monthly billing claims for
12reimbursement purposes. Following development of these
13procedures, the Department shall, by July 1, 2016, test the
14viability of the new system and implement any necessary
15operational or structural changes to its information
16technology platforms in order to allow for the direct
17acceptance and payment of nursing home claims.
18    Notwithstanding any other law to the contrary, the
19Illinois Department shall, within 365 days after August 15,
202014 (the effective date of Public Act 98-963), establish
21procedures to permit ID/DD facilities licensed under the ID/DD
22Community Care Act and MC/DD facilities licensed under the
23MC/DD Act to submit monthly billing claims for reimbursement
24purposes. Following development of these procedures, the
25Department shall have an additional 365 days to test the
26viability of the new system and to ensure that any necessary



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



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



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



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



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



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



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



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



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1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the
5State where they are not currently available or are
6undeveloped; and (iii) notwithstanding any other provision of
7law, subject to federal approval, on and after July 1, 2012, an
8increase in the determination of need (DON) scores from 29 to
937 for applicants for institutional and home and
10community-based long term care; if and only if federal
11approval is not granted, the Department may, in conjunction
12with other affected agencies, implement utilization controls
13or changes in benefit packages to effectuate a similar savings
14amount for this population; and (iv) no later than July 1,
152013, minimum level of care eligibility criteria for
16institutional and home and community-based long term care; and
17(v) no later than October 1, 2013, establish procedures to
18permit long term care providers access to eligibility scores
19for individuals with an admission date who are seeking or
20receiving services from the long term care provider. In order
21to select the minimum level of care eligibility criteria, the
22Governor shall establish a workgroup that includes affected
23agency representatives and stakeholders representing the
24institutional and home and community-based long term care
25interests. This Section shall not restrict the Department from
26implementing lower level of care eligibility criteria for



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1community-based services in circumstances where federal
2approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation
7and programs for monitoring of utilization of health care
8services and facilities, as it affects persons eligible for
9medical assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The requirement for reporting to the General
25Assembly shall be satisfied by filing copies of the report as
26required by Section 3.1 of the General Assembly Organization



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



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



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1to, naloxone hydrochloride or any other similarly acting drug
2approved by the U.S. Food and Drug Administration. The
3Department shall not impose a copayment on the coverage
4provided for naloxone hydrochloride under the medical
5assistance program.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a
23dental hygienist, as defined under the Illinois Dental
24Practice Act, working under the general supervision of a
25dentist and employed by a federally qualified health center.
26    Within 90 days after October 8, 2021 (the effective date



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1of Public Act 102-665), the Department shall seek federal
2approval of a State Plan amendment to expand coverage for
3family planning services that includes presumptive eligibility
4to individuals whose income is at or below 208% of the federal
5poverty level. Coverage under this Section shall be effective
6beginning no later than December 1, 2022.
7    Subject to approval by the federal Centers for Medicare
8and Medicaid Services of a Title XIX State Plan amendment
9electing the Program of All-Inclusive Care for the Elderly
10(PACE) as a State Medicaid option, as provided for by Subtitle
11I (commencing with Section 4801) of Title IV of the Balanced
12Budget Act of 1997 (Public Law 105-33) and Part 460
13(commencing with Section 460.2) of Subchapter E of Title 42 of
14the Code of Federal Regulations, PACE program services shall
15become a covered benefit of the medical assistance program,
16subject to criteria established in accordance with all
17applicable laws.
18    Notwithstanding any other provision of this Code,
19community-based pediatric palliative care from a trained
20interdisciplinary team shall be covered under the medical
21assistance program as provided in Section 15 of the Pediatric
22Palliative Care Act.
23    Notwithstanding any other provision of this Code, within
2412 months after June 2, 2022 (the effective date of Public Act
25102-1037) this amendatory Act of the 102nd General Assembly
26and subject to federal approval, acupuncture services



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1performed by an acupuncturist licensed under the Acupuncture
2Practice Act who is acting within the scope of his or her
3license shall be covered under the medical assistance program.
4The Department shall apply for any federal waiver or State
5Plan amendment, if required, to implement this paragraph. The
6Department may adopt any rules, including standards and
7criteria, necessary to implement this paragraph.
8    Notwithstanding any other provision of this Code, the
9medical assistance program shall, subject to appropriation and
10federal approval, reimburse hospitals for costs associated
11with a newborn screening test for the presence of
12metachromatic leukodystrophy, as required under the Newborn
13Metabolic Screening Act, at a rate not less than the fee
14charged by the Department of Public Health. The Department
15shall seek federal approval before the implementation of the
16newborn screening test fees by the Department of Public
18(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
19102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
2035, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
2155-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
22102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
231-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
24102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
251-1-23; revised 2-5-23.)".