Illinois General Assembly - Full Text of HB4449
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Full Text of HB4449  102nd General Assembly




State of Illinois
2021 and 2022


Introduced 1/21/2022, by Rep. Cyril Nichols


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that naprapathic services shall be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment, if required, to implement the amendatory Act. Grants the Department rulemaking authority. Provides that implementation of the amendatory Act is contingent on federal approval.

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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (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
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant individuals, provided by an individual licensed
22to practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or



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



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



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



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



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



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



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



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



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



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1would require the State, pursuant to any provision of the
2Patient Protection and Affordable Care Act (Public Law
3111-148), including, but not limited to, 42 U.S.C.
418031(d)(3)(B) or any successor provision, to defray the cost
5of any coverage for breast tomosynthesis outlined in this
6paragraph, then the requirement that an insurer cover breast
7tomosynthesis is inoperative other than any such coverage
8authorized under Section 1902 of the Social Security Act, 42
9U.S.C. 1396a, and the State shall not assume any obligation
10for the cost of coverage for breast tomosynthesis set forth in
11this paragraph.
12    On and after January 1, 2016, the Department shall ensure
13that all networks of care for adult clients of the Department
14include access to at least one breast imaging Center of
15Imaging Excellence as certified by the American College of
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall
19be reimbursed for screening and diagnostic mammography at the
20same rate as the Medicare program's rates, including the
21increased reimbursement for digital mammography.
22    The Department shall convene an expert panel including
23representatives of hospitals, free-standing mammography
24facilities, and doctors, including radiologists, to establish
25quality standards for mammography.
26    On and after January 1, 2017, providers participating in a



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



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2    The Department shall establish a performance goal for
3primary care providers with respect to their female patients
4over age 40 receiving an annual mammogram. This performance
5goal shall be used to provide additional reimbursement in the
6form of a quality performance bonus to primary care providers
7who meet that goal.
8    The Department shall devise a means of case-managing or
9patient navigation for beneficiaries diagnosed with breast
10cancer. This program shall initially operate as a pilot
11program in areas of the State with the highest incidence of
12mortality related to breast cancer. At least one pilot program
13site shall be in the metropolitan Chicago area and at least one
14site shall be outside the metropolitan Chicago area. On or
15after July 1, 2016, the pilot program shall be expanded to
16include one site in western Illinois, one site in southern
17Illinois, one site in central Illinois, and 4 sites within
18metropolitan Chicago. An evaluation of the pilot program shall
19be carried out measuring health outcomes and cost of care for
20those served by the pilot program compared to similarly
21situated patients who are not served by the pilot program.
22    The Department shall require all networks of care to
23develop a means either internally or by contract with experts
24in navigation and community outreach to navigate cancer
25patients to comprehensive care in a timely fashion. The
26Department shall require all networks of care to include



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1access for patients diagnosed with cancer to at least one
2academic commission on cancer-accredited cancer program as an
3in-network covered benefit.
4    On or after July 1, 2022, individuals who are otherwise
5eligible for medical assistance under this Article shall
6receive coverage for perinatal depression screenings for the
712-month period beginning on the last day of their pregnancy.
8Medical assistance coverage under this paragraph shall be
9conditioned on the use of a screening instrument approved by
10the Department.
11    Any medical or health care provider shall immediately
12recommend, to any pregnant individual who is being provided
13prenatal services and is suspected of having a substance use
14disorder as defined in the Substance Use Disorder Act,
15referral to a local substance use disorder treatment program
16licensed by the Department of Human Services or to a licensed
17hospital which provides substance abuse treatment services.
18The Department of Healthcare and Family Services shall assure
19coverage for the cost of treatment of the drug abuse or
20addiction for pregnant recipients in accordance with the
21Illinois Medicaid Program in conjunction with the Department
22of Human Services.
23    All medical providers providing medical assistance to
24pregnant individuals under this Code shall receive information
25from the Department on the availability of services under any
26program providing case management services for addicted



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



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



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1        (3) Persons receiving medical services through
2    Partnerships may receive medical and case management
3    services above the level usually offered through the
4    medical assistance program.
5    Medical providers shall be required to meet certain
6qualifications to participate in Partnerships to ensure the
7delivery of high quality medical services. These
8qualifications shall be determined by rule of the Illinois
9Department and may be higher than qualifications for
10participation in the medical assistance program. Partnership
11sponsors may prescribe reasonable additional qualifications
12for participation by medical providers, only with the prior
13written approval of the Illinois Department.
14    Nothing in this Section shall limit the free choice of
15practitioners, hospitals, and other providers of medical
16services by clients. In order to ensure patient freedom of
17choice, the Illinois Department shall immediately promulgate
18all rules and take all other necessary actions so that
19provided services may be accessed from therapeutically
20certified optometrists to the full extent of the Illinois
21Optometric Practice Act of 1987 without discriminating between
22service providers.
23    The Department shall apply for a waiver from the United
24States Health Care Financing Administration to allow for the
25implementation of Partnerships under this Section.
26    The Illinois Department shall require health care



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1providers to maintain records that document the medical care
2and services provided to recipients of Medical Assistance
3under this Article. Such records must be retained for a period
4of not less than 6 years from the date of service or as
5provided by applicable State law, whichever period is longer,
6except that if an audit is initiated within the required
7retention period then the records must be retained until the
8audit is completed and every exception is resolved. The
9Illinois Department shall require health care providers to
10make available, when authorized by the patient, in writing,
11the medical records in a timely fashion to other health care
12providers who are treating or serving persons eligible for
13Medical Assistance under this Article. All dispensers of
14medical services shall be required to maintain and retain
15business and professional records sufficient to fully and
16accurately document the nature, scope, details and receipt of
17the health care provided to persons eligible for medical
18assistance under this Code, in accordance with regulations
19promulgated by the Illinois Department. The rules and
20regulations shall require that proof of the receipt of
21prescription drugs, dentures, prosthetic devices and
22eyeglasses by eligible persons under this Section accompany
23each claim for reimbursement submitted by the dispenser of
24such medical services. No such claims for reimbursement shall
25be approved for payment by the Illinois Department without
26such proof of receipt, unless the Illinois Department shall



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1have put into effect and shall be operating a system of
2post-payment audit and review which shall, on a sampling
3basis, be deemed adequate by the Illinois Department to assure
4that such drugs, dentures, prosthetic devices and eyeglasses
5for which payment is being made are actually being received by
6eligible recipients. Within 90 days after September 16, 1984
7(the effective date of Public Act 83-1439), the Illinois
8Department shall establish a current list of acquisition costs
9for all prosthetic devices and any other items recognized as
10medical equipment and supplies reimbursable under this Article
11and shall update such list on a quarterly basis, except that
12the acquisition costs of all prescription drugs shall be
13updated no less frequently than every 30 days as required by
14Section 5-5.12.
15    Notwithstanding any other law to the contrary, the
16Illinois Department shall, within 365 days after July 22, 2013
17(the effective date of Public Act 98-104), establish
18procedures to permit skilled care facilities licensed under
19the Nursing Home Care Act to submit monthly billing claims for
20reimbursement purposes. Following development of these
21procedures, the Department shall, by July 1, 2016, test the
22viability of the new system and implement any necessary
23operational or structural changes to its information
24technology platforms in order to allow for the direct
25acceptance and payment of nursing home claims.
26    Notwithstanding any other law to the contrary, the



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1Illinois Department shall, within 365 days after August 15,
22014 (the effective date of Public Act 98-963), establish
3procedures to permit ID/DD facilities licensed under the ID/DD
4Community Care Act and MC/DD facilities licensed under the
5MC/DD Act to submit monthly billing claims for reimbursement
6purposes. Following development of these procedures, the
7Department shall have an additional 365 days to test the
8viability of the new system and to ensure that any necessary
9operational or structural changes to its information
10technology platforms are implemented.
11    The Illinois Department shall require all dispensers of
12medical services, other than an individual practitioner or
13group of practitioners, desiring to participate in the Medical
14Assistance program established under this Article to disclose
15all financial, beneficial, ownership, equity, surety or other
16interests in any and all firms, corporations, partnerships,
17associations, business enterprises, joint ventures, agencies,
18institutions or other legal entities providing any form of
19health care services in this State under this Article.
20    The Illinois Department may require that all dispensers of
21medical services desiring to participate in the medical
22assistance program established under this Article disclose,
23under such terms and conditions as the Illinois Department may
24by rule establish, all inquiries from clients and attorneys
25regarding medical bills paid by the Illinois Department, which
26inquiries could indicate potential existence of claims or



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



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



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1        (3) In the case of a provider for whom the Illinois
2    Department initiates the monthly billing process.
3        (4) In the case of a provider operated by a unit of
4    local government with a population exceeding 3,000,000
5    when local government funds finance federal participation
6    for claims payments.
7    For claims for services rendered during a period for which
8a recipient received retroactive eligibility, claims must be
9filed within 180 days after the Department determines the
10applicant is eligible. For claims for which the Illinois
11Department is not the primary payer, claims must be submitted
12to the Illinois Department within 180 days after the final
13adjudication by the primary payer.
14    In the case of long term care facilities, within 120
15calendar days of receipt by the facility of required
16prescreening information, new admissions with associated
17admission documents shall be submitted through the Medical
18Electronic Data Interchange (MEDI) or the Recipient
19Eligibility Verification (REV) System or shall be submitted
20directly to the Department of Human Services using required
21admission forms. Effective September 1, 2014, admission
22documents, including all prescreening information, must be
23submitted through MEDI or REV. Confirmation numbers assigned
24to an accepted transaction shall be retained by a facility to
25verify timely submittal. Once an admission transaction has
26been completed, all resubmitted claims following prior



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1rejection are subject to receipt no later than 180 days after
2the admission transaction has been completed.
3    Claims that are not submitted and received in compliance
4with the foregoing requirements shall not be eligible for
5payment under the medical assistance program, and the State
6shall have no liability for payment of those claims.
7    To the extent consistent with applicable information and
8privacy, security, and disclosure laws, State and federal
9agencies and departments shall provide the Illinois Department
10access to confidential and other information and data
11necessary to perform eligibility and payment verifications and
12other Illinois Department functions. This includes, but is not
13limited to: information pertaining to licensure;
14certification; earnings; immigration status; citizenship; wage
15reporting; unearned and earned income; pension income;
16employment; supplemental security income; social security
17numbers; National Provider Identifier (NPI) numbers; the
18National Practitioner Data Bank (NPDB); program and agency
19exclusions; taxpayer identification numbers; tax delinquency;
20corporate information; and death records.
21    The Illinois Department shall enter into agreements with
22State agencies and departments, and is authorized to enter
23into agreements with federal agencies and departments, under
24which such agencies and departments shall share data necessary
25for medical assistance program integrity functions and
26oversight. The Illinois Department shall develop, in



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



HB4449- 26 -LRB102 22604 KTG 31747 b

1procedures, standards and criteria by rule for the
2acquisition, repair and replacement of orthotic and prosthetic
3devices and durable medical equipment. Such rules shall
4provide, but not be limited to, the following services: (1)
5immediate repair or replacement of such devices by recipients;
6and (2) rental, lease, purchase or lease-purchase of durable
7medical equipment in a cost-effective manner, taking into
8consideration the recipient's medical prognosis, the extent of
9the recipient's needs, and the requirements and costs for
10maintaining such equipment. Subject to prior approval, such
11rules shall enable a recipient to temporarily acquire and use
12alternative or substitute devices or equipment pending repairs
13or replacements of any device or equipment previously
14authorized for such recipient by the Department.
15Notwithstanding any provision of Section 5-5f to the contrary,
16the Department may, by rule, exempt certain replacement
17wheelchair parts from prior approval and, for wheelchairs,
18wheelchair parts, wheelchair accessories, and related seating
19and positioning items, determine the wholesale price by
20methods other than actual acquisition costs.
21    The Department shall require, by rule, all providers of
22durable medical equipment to be accredited by an accreditation
23organization approved by the federal Centers for Medicare and
24Medicaid Services and recognized by the Department in order to
25bill the Department for providing durable medical equipment to
26recipients. No later than 15 months after the effective date



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1of the rule adopted pursuant to this paragraph, all providers
2must meet the accreditation requirement.
3    In order to promote environmental responsibility, meet the
4needs of recipients and enrollees, and achieve significant
5cost savings, the Department, or a managed care organization
6under contract with the Department, may provide recipients or
7managed care enrollees who have a prescription or Certificate
8of Medical Necessity access to refurbished durable medical
9equipment under this Section (excluding prosthetic and
10orthotic devices as defined in the Orthotics, Prosthetics, and
11Pedorthics Practice Act and complex rehabilitation technology
12products and associated services) through the State's
13assistive technology program's reutilization program, using
14staff with the Assistive Technology Professional (ATP)
15Certification if the refurbished durable medical equipment:
16(i) is available; (ii) is less expensive, including shipping
17costs, than new durable medical equipment of the same type;
18(iii) is able to withstand at least 3 years of use; (iv) is
19cleaned, disinfected, sterilized, and safe in accordance with
20federal Food and Drug Administration regulations and guidance
21governing the reprocessing of medical devices in health care
22settings; and (v) equally meets the needs of the recipient or
23enrollee. The reutilization program shall confirm that the
24recipient or enrollee is not already in receipt of the same or
25similar equipment from another service provider, and that the
26refurbished durable medical equipment equally meets the needs



HB4449- 28 -LRB102 22604 KTG 31747 b

1of the recipient or enrollee. Nothing in this paragraph shall
2be construed to limit recipient or enrollee choice to obtain
3new durable medical equipment or place any additional prior
4authorization conditions on enrollees of managed care
6    The Department shall execute, relative to the nursing home
7prescreening project, written inter-agency agreements with the
8Department of Human Services and the Department on Aging, to
9effect the following: (i) intake procedures and common
10eligibility criteria for those persons who are receiving
11non-institutional services; and (ii) the establishment and
12development of non-institutional services in areas of the
13State where they are not currently available or are
14undeveloped; and (iii) notwithstanding any other provision of
15law, subject to federal approval, on and after July 1, 2012, an
16increase in the determination of need (DON) scores from 29 to
1737 for applicants for institutional and home and
18community-based long term care; if and only if federal
19approval is not granted, the Department may, in conjunction
20with other affected agencies, implement utilization controls
21or changes in benefit packages to effectuate a similar savings
22amount for this population; and (iv) no later than July 1,
232013, minimum level of care eligibility criteria for
24institutional and home and community-based long term care; and
25(v) no later than October 1, 2013, establish procedures to
26permit long term care providers access to eligibility scores



HB4449- 29 -LRB102 22604 KTG 31747 b

1for individuals with an admission date who are seeking or
2receiving services from the long term care provider. In order
3to select the minimum level of care eligibility criteria, the
4Governor shall establish a workgroup that includes affected
5agency representatives and stakeholders representing the
6institutional and home and community-based long term care
7interests. This Section shall not restrict the Department from
8implementing lower level of care eligibility criteria for
9community-based services in circumstances where federal
10approval has been granted.
11    The Illinois Department shall develop and operate, in
12cooperation with other State Departments and agencies and in
13compliance with applicable federal laws and regulations,
14appropriate and effective systems of health care evaluation
15and programs for monitoring of utilization of health care
16services and facilities, as it affects persons eligible for
17medical assistance under this Code.
18    The Illinois Department shall report annually to the
19General Assembly, no later than the second Friday in April of
201979 and each year thereafter, in regard to:
21        (a) actual statistics and trends in utilization of
22    medical services by public aid recipients;
23        (b) actual statistics and trends in the provision of
24    the various medical services by medical vendors;
25        (c) current rate structures and proposed changes in
26    those rate structures for the various medical vendors; and



HB4449- 30 -LRB102 22604 KTG 31747 b

1        (d) efforts at utilization review and control by the
2    Illinois Department.
3    The period covered by each report shall be the 3 years
4ending on the June 30 prior to the report. The report shall
5include suggested legislation for consideration by the General
6Assembly. The requirement for reporting to the General
7Assembly shall be satisfied by filing copies of the report as
8required by Section 3.1 of the General Assembly Organization
9Act, and filing such additional copies with the State
10Government Report Distribution Center for the General Assembly
11as is required under paragraph (t) of Section 7 of the State
12Library Act.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate
22of reimbursement for services or other payments in accordance
23with Section 5-5e.
24    Because kidney transplantation can be an appropriate,
25cost-effective alternative to renal dialysis when medically
26necessary and notwithstanding the provisions of Section 1-11



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1of this Code, beginning October 1, 2014, the Department shall
2cover kidney transplantation for noncitizens with end-stage
3renal disease who are not eligible for comprehensive medical
4benefits, who meet the residency requirements of Section 5-3
5of this Code, and who would otherwise meet the financial
6requirements of the appropriate class of eligible persons
7under Section 5-2 of this Code. To qualify for coverage of
8kidney transplantation, such person must be receiving
9emergency renal dialysis services covered by the Department.
10Providers under this Section shall be prior approved and
11certified by the Department to perform kidney transplantation
12and the services under this Section shall be limited to
13services associated with kidney transplantation.
14    Notwithstanding any other provision of this Code to the
15contrary, on or after July 1, 2015, all FDA approved forms of
16medication assisted treatment prescribed for the treatment of
17alcohol dependence or treatment of opioid dependence shall be
18covered under both fee for service and managed care medical
19assistance programs for persons who are otherwise eligible for
20medical assistance under this Article and shall not be subject
21to any (1) utilization control, other than those established
22under the American Society of Addiction Medicine patient
23placement criteria, (2) prior authorization mandate, or (3)
24lifetime restriction limit mandate.
25    On or after July 1, 2015, opioid antagonists prescribed
26for the treatment of an opioid overdose, including the



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1medication product, administration devices, and any pharmacy
2fees or hospital fees related to the dispensing, distribution,
3and administration of the opioid antagonist, shall be covered
4under the medical assistance program for persons who are
5otherwise eligible for medical assistance under this Article.
6As used in this Section, "opioid antagonist" means a drug that
7binds to opioid receptors and blocks or inhibits the effect of
8opioids acting on those receptors, including, but not limited
9to, naloxone hydrochloride or any other similarly acting drug
10approved by the U.S. Food and Drug Administration.
11    Upon federal approval, the Department shall provide
12coverage and reimbursement for all drugs that are approved for
13marketing by the federal Food and Drug Administration and that
14are recommended by the federal Public Health Service or the
15United States Centers for Disease Control and Prevention for
16pre-exposure prophylaxis and related pre-exposure prophylaxis
17services, including, but not limited to, HIV and sexually
18transmitted infection screening, treatment for sexually
19transmitted infections, medical monitoring, assorted labs, and
20counseling to reduce the likelihood of HIV infection among
21individuals who are not infected with HIV but who are at high
22risk of HIV infection.
23    A federally qualified health center, as defined in Section
241905(l)(2)(B) of the federal Social Security Act, shall be
25reimbursed by the Department in accordance with the federally
26qualified health center's encounter rate for services provided



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1to medical assistance recipients that are performed by a
2dental hygienist, as defined under the Illinois Dental
3Practice Act, working under the general supervision of a
4dentist and employed by a federally qualified health center.
5    Within 90 days after October 8, 2021 (the effective date
6of Public Act 102-665) this amendatory Act of the 102nd
7General Assembly, the Department shall seek federal approval
8of a State Plan amendment to expand coverage for family
9planning services that includes presumptive eligibility to
10individuals whose income is at or below 208% of the federal
11poverty level. Coverage under this Section shall be effective
12beginning no later than December 1, 2022.
13    Subject to approval by the federal Centers for Medicare
14and Medicaid Services of a Title XIX State Plan amendment
15electing the Program of All-Inclusive Care for the Elderly
16(PACE) as a State Medicaid option, as provided for by Subtitle
17I (commencing with Section 4801) of Title IV of the Balanced
18Budget Act of 1997 (Public Law 105-33) and Part 460
19(commencing with Section 460.2) of Subchapter E of Title 42 of
20the Code of Federal Regulations, PACE program services shall
21become a covered benefit of the medical assistance program,
22subject to criteria established in accordance with all
23applicable laws.
24    Notwithstanding any other provision of this Code,
25community-based pediatric palliative care from a trained
26interdisciplinary team shall be covered under the medical



HB4449- 34 -LRB102 22604 KTG 31747 b

1assistance program as provided in Section 15 of the Pediatric
2Palliative Care Act.
3    Notwithstanding any other provision of this Code,
4naprapathic services performed by a naprapath licensed under
5the Naprapathic Practice Act who is acting within the scope of
6his or her license shall be covered under the medical
7assistance program. The Department shall apply for any federal
8waiver or State Plan amendment, if required, to implement this
9paragraph. The Department may adopt any rules necessary to
10implement this paragraph. Implementation of this paragraph is
11contingent on federal approval.
12(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
13102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1435, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1555-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
16102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
171-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)