Illinois General Assembly - Full Text of SB2658
Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Full Text of SB2658  103rd General Assembly


Sen. Julie A. Morrison

Filed: 3/7/2024





10300SB2658sam001LRB103 35285 AWJ 70200 a


2    AMENDMENT NO. ______. Amend Senate Bill 2658 on page 1,
3immediately below line 3, by inserting the following:
4    "Section 3. 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



10300SB2658sam001- 2 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 3 -LRB103 35285 AWJ 70200 a

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.



10300SB2658sam001- 4 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 5 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 6 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 7 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 8 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 9 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 10 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 11 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 12 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 13 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 14 -LRB103 35285 AWJ 70200 a

1metropolitan Chicago. An evaluation of the pilot program shall
2be carried out measuring health outcomes and cost of care for
3those served by the pilot program compared to similarly
4situated patients who are not served by the pilot program.
5    The Department shall require all networks of care to
6develop a means either internally or by contract with experts
7in navigation and community outreach to navigate cancer
8patients to comprehensive care in a timely fashion. The
9Department shall require all networks of care to include
10access for patients diagnosed with cancer to at least one
11academic commission on cancer-accredited cancer program as an
12in-network covered benefit.
13    The Department shall provide coverage and reimbursement
14for a human papillomavirus (HPV) vaccine that is approved for
15marketing by the federal Food and Drug Administration for all
16persons between the ages of 9 and 45. Subject to federal
17approval, the Department shall provide coverage and
18reimbursement for a human papillomavirus (HPV) vaccine for
19persons of the age of 46 and above who have been diagnosed with
20cervical dysplasia with a high risk of recurrence or
21progression. The Department shall disallow any
22preauthorization requirements for the administration of the
23human papillomavirus (HPV) vaccine.
24    On or after July 1, 2022, individuals who are otherwise
25eligible for medical assistance under this Article shall
26receive coverage for perinatal depression screenings for the



10300SB2658sam001- 15 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 16 -LRB103 35285 AWJ 70200 a

1a public awareness campaign, may provide information
2concerning treatment for alcoholism and drug abuse and
3addiction, prenatal health care, and other pertinent programs
4directed at reducing the number of drug-affected infants born
5to recipients of medical assistance.
6    Neither the Department of Healthcare and Family Services
7nor the Department of Human Services shall sanction the
8recipient solely on the basis of the recipient's substance
10    The Illinois Department shall establish such regulations
11governing the dispensing of health services under this Article
12as it shall deem appropriate. The Department should seek the
13advice of formal professional advisory committees appointed by
14the Director of the Illinois Department for the purpose of
15providing regular advice on policy and administrative matters,
16information dissemination and educational activities for
17medical and health care providers, and consistency in
18procedures to the Illinois Department.
19    The Illinois Department may develop and contract with
20Partnerships of medical providers to arrange medical services
21for persons eligible under Section 5-2 of this Code.
22Implementation of this Section may be by demonstration
23projects in certain geographic areas. The Partnership shall be
24represented by a sponsor organization. The Department, by
25rule, shall develop qualifications for sponsors of
26Partnerships. Nothing in this Section shall be construed to



10300SB2658sam001- 17 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 18 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 19 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 20 -LRB103 35285 AWJ 70200 a

1(the effective date of Public Act 83-1439), the Illinois
2Department shall establish a current list of acquisition costs
3for all prosthetic devices and any other items recognized as
4medical equipment and supplies reimbursable under this Article
5and shall update such list on a quarterly basis, except that
6the acquisition costs of all prescription drugs shall be
7updated no less frequently than every 30 days as required by
8Section 5-5.12.
9    Notwithstanding any other law to the contrary, the
10Illinois Department shall, within 365 days after July 22, 2013
11(the effective date of Public Act 98-104), establish
12procedures to permit skilled care facilities licensed under
13the Nursing Home Care Act to submit monthly billing claims for
14reimbursement purposes. Following development of these
15procedures, the Department shall, by July 1, 2016, test the
16viability of the new system and implement any necessary
17operational or structural changes to its information
18technology platforms in order to allow for the direct
19acceptance and payment of nursing home claims.
20    Notwithstanding any other law to the contrary, the
21Illinois Department shall, within 365 days after August 15,
222014 (the effective date of Public Act 98-963), establish
23procedures to permit ID/DD facilities licensed under the ID/DD
24Community Care Act and MC/DD facilities licensed under the
25MC/DD Act to submit monthly billing claims for reimbursement
26purposes. Following development of these procedures, the



10300SB2658sam001- 21 -LRB103 35285 AWJ 70200 a

1Department shall have an additional 365 days to test the
2viability of the new system and to ensure that any necessary
3operational or structural changes to its information
4technology platforms are implemented.
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or
21liens for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the
24period of conditional enrollment, the Department may terminate
25the vendor's eligibility to participate in, or may disenroll
26the vendor from, the medical assistance program without cause.



10300SB2658sam001- 22 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 23 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 24 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 25 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 26 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 27 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 28 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 29 -LRB103 35285 AWJ 70200 a

1prescreening project, written inter-agency agreements with the
2Department of Human Services and the Department on Aging, to
3effect the following: (i) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (ii) the establishment and
6development of non-institutional services in areas of the
7State where they are not currently available or are
8undeveloped; and (iii) notwithstanding any other provision of
9law, subject to federal approval, on and after July 1, 2012, an
10increase in the determination of need (DON) scores from 29 to
1137 for applicants for institutional and home and
12community-based long term care; if and only if federal
13approval is not granted, the Department may, in conjunction
14with other affected agencies, implement utilization controls
15or changes in benefit packages to effectuate a similar savings
16amount for this population; and (iv) no later than July 1,
172013, minimum level of care eligibility criteria for
18institutional and home and community-based long term care; and
19(v) no later than October 1, 2013, establish procedures to
20permit long term care providers access to eligibility scores
21for individuals with an admission date who are seeking or
22receiving services from the long term care provider. In order
23to select the minimum level of care eligibility criteria, the
24Governor shall establish a workgroup that includes affected
25agency representatives and stakeholders representing the
26institutional and home and community-based long term care



10300SB2658sam001- 30 -LRB103 35285 AWJ 70200 a

1interests. This Section shall not restrict the Department from
2implementing lower level of care eligibility criteria for
3community-based services in circumstances where federal
4approval has been granted.
5    The Illinois Department shall develop and operate, in
6cooperation with other State Departments and agencies and in
7compliance with applicable federal laws and regulations,
8appropriate and effective systems of health care evaluation
9and programs for monitoring of utilization of health care
10services and facilities, as it affects persons eligible for
11medical assistance under this Code.
12    The Illinois Department shall report annually to the
13General Assembly, no later than the second Friday in April of
141979 and each year thereafter, in regard to:
15        (a) actual statistics and trends in utilization of
16    medical services by public aid recipients;
17        (b) actual statistics and trends in the provision of
18    the various medical services by medical vendors;
19        (c) current rate structures and proposed changes in
20    those rate structures for the various medical vendors; and
21        (d) efforts at utilization review and control by the
22    Illinois Department.
23    The period covered by each report shall be the 3 years
24ending on the June 30 prior to the report. The report shall
25include suggested legislation for consideration by the General
26Assembly. The requirement for reporting to the General



10300SB2658sam001- 31 -LRB103 35285 AWJ 70200 a

1Assembly shall be satisfied by filing copies of the report as
2required by Section 3.1 of the General Assembly Organization
3Act, and filing such additional copies with the State
4Government Report Distribution Center for the General Assembly
5as is required under paragraph (t) of Section 7 of the State
6Library Act.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13    On and after July 1, 2012, the Department shall reduce any
14rate of reimbursement for services or other payments or alter
15any methodologies authorized by this Code to reduce any rate
16of reimbursement for services or other payments in accordance
17with Section 5-5e.
18    Because kidney transplantation can be an appropriate,
19cost-effective alternative to renal dialysis when medically
20necessary and notwithstanding the provisions of Section 1-11
21of this Code, beginning October 1, 2014, the Department shall
22cover kidney transplantation for noncitizens with end-stage
23renal disease who are not eligible for comprehensive medical
24benefits, who meet the residency requirements of Section 5-3
25of this Code, and who would otherwise meet the financial
26requirements of the appropriate class of eligible persons



10300SB2658sam001- 32 -LRB103 35285 AWJ 70200 a

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



10300SB2658sam001- 33 -LRB103 35285 AWJ 70200 a

1binds to opioid receptors and blocks or inhibits the effect of
2opioids acting on those receptors, including, but not limited
3to, naloxone hydrochloride or any other similarly acting drug
4approved by the U.S. Food and Drug Administration. The
5Department shall not impose a copayment on the coverage
6provided for naloxone hydrochloride under the medical
7assistance program.
8    Upon federal approval, the Department shall provide
9coverage and reimbursement for all drugs that are approved for
10marketing by the federal Food and Drug Administration and that
11are recommended by the federal Public Health Service or the
12United States Centers for Disease Control and Prevention for
13pre-exposure prophylaxis and related pre-exposure prophylaxis
14services, including, but not limited to, HIV and sexually
15transmitted infection screening, treatment for sexually
16transmitted infections, medical monitoring, assorted labs, and
17counseling to reduce the likelihood of HIV infection among
18individuals who are not infected with HIV but who are at high
19risk of HIV infection.
20    A federally qualified health center, as defined in Section
211905(l)(2)(B) of the federal Social Security Act, shall be
22reimbursed by the Department in accordance with the federally
23qualified health center's encounter rate for services provided
24to medical assistance recipients that are performed by a
25dental hygienist, as defined under the Illinois Dental
26Practice Act, working under the general supervision of a



10300SB2658sam001- 34 -LRB103 35285 AWJ 70200 a

1dentist and employed by a federally qualified health center.
2    Within 90 days after October 8, 2021 (the effective date
3of Public Act 102-665), the Department shall seek federal
4approval of a State Plan amendment to expand coverage for
5family planning services that includes presumptive eligibility
6to individuals whose income is at or below 208% of the federal
7poverty level. Coverage under this Section shall be effective
8beginning no later than December 1, 2022.
9    Subject to approval by the federal Centers for Medicare
10and Medicaid Services of a Title XIX State Plan amendment
11electing the Program of All-Inclusive Care for the Elderly
12(PACE) as a State Medicaid option, as provided for by Subtitle
13I (commencing with Section 4801) of Title IV of the Balanced
14Budget Act of 1997 (Public Law 105-33) and Part 460
15(commencing with Section 460.2) of Subchapter E of Title 42 of
16the Code of Federal Regulations, PACE program services shall
17become a covered benefit of the medical assistance program,
18subject to criteria established in accordance with all
19applicable laws.
20    Notwithstanding any other provision of this Code,
21community-based pediatric palliative care from a trained
22interdisciplinary team shall be covered under the medical
23assistance program as provided in Section 15 of the Pediatric
24Palliative Care Act.
25    Notwithstanding any other provision of this Code, within
2612 months after June 2, 2022 (the effective date of Public Act



10300SB2658sam001- 35 -LRB103 35285 AWJ 70200 a

1102-1037) and subject to federal approval, acupuncture
2services performed by an acupuncturist licensed under the
3Acupuncture Practice Act who is acting within the scope of his
4or her license shall be covered under the medical assistance
5program. The Department shall apply for any federal waiver or
6State Plan amendment, if required, to implement this
7paragraph. The Department may adopt any rules, including
8standards and criteria, necessary to implement this paragraph.
9    Notwithstanding any other provision of this Code, the
10medical assistance program shall, subject to appropriation and
11federal approval, reimburse hospitals for costs associated
12with a newborn screening test for the presence of
13metachromatic leukodystrophy, as required under the Newborn
14Metabolic Screening Act, at a rate not less than the fee
15charged by the Department of Public Health. Notwithstanding
16any other provision of this Code, the medical assistance
17program shall, subject to federal approval, also reimburse
18hospitals for costs associated with all newborn screening
19tests added on and after the effective date of this amendatory
20Act of the 103rd General Assembly to the Newborn Metabolic
21Screening Act and required to be performed under that Act at a
22rate not less than the fee charged by the Department of Public
23Health. The Department shall seek federal approval before the
24implementation of the newborn screening test fees by the
25Department of Public Health.
26    Notwithstanding any other provision of this Code,



10300SB2658sam001- 36 -LRB103 35285 AWJ 70200 a

1beginning on January 1, 2024, subject to federal approval,
2cognitive assessment and care planning services provided to a
3person who experiences signs or symptoms of cognitive
4impairment, as defined by the Diagnostic and Statistical
5Manual of Mental Disorders, Fifth Edition, shall be covered
6under the medical assistance program for persons who are
7otherwise eligible for medical assistance under this Article.
8    Notwithstanding any other provision of this Code,
9medically necessary reconstructive services that are intended
10to restore physical appearance shall be covered under the
11medical assistance program for persons who are otherwise
12eligible for medical assistance under this Article. As used in
13this paragraph, "reconstructive services" means treatments
14performed on structures of the body damaged by trauma to
15restore physical appearance.
16(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
17102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1855, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
19eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
20102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
215-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
22102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
231-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
24103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
251-1-24; revised 12-15-23.)".