Public Act 102-0043
 
SB2294 EnrolledLRB102 10643 BMS 15972 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
Article 3.

 
    Section 3-1. Short title. This Act may be cited as the
Illinois Certified Community Behavioral Health Clinics Act.
 
    Section 3-5. Certified Community Behavioral Health Clinic
program. The Department of Healthcare and Family Services, in
collaboration with the Department of Human Services and with
meaningful input from customers and key behavioral health
stakeholders, shall develop a Comprehensive Statewide
Behavioral Health Strategy and shall submit this Strategy to
the Governor and General Assembly no later than July 1, 2022.
The Strategy shall address key components of current and past
legislation as well as current initiatives related to
behavioral health services in order to develop a cohesive
behavioral health system that reduces the administrative
burden for customers and providers and includes: (i)
comprehensive home and community-based services; (ii)
integrated mental health, substance use disorder, and physical
health services, and social determinants of health; and (iii)
innovative payment models that support providers in offering
integrated services that are clinically effective and fiscally
supported. The Strategy shall consolidate required pilots and
initiatives into a cohesive behavioral health system designed
to serve both adults and children in the least restrictive
setting, as early as possible, once behavioral health needs
have been identified, and through evidence-informed practices
identified by the Substance Abuse and Mental Health Services
Administration (SAMHSA) and other national experts. The
Strategy shall take into consideration initiatives such as the
Healthcare Transformation Collaboratives program; integrated
health homes; services offered under federal Medicaid waiver
authorities, including Sections 1915(i) and 1115 of the Social
Security Act; requirements for certified community behavioral
health centers; enhanced team-based services; housing and
employment supports; and other initiatives identified by
customers and stakeholders. The Strategy shall also identify
the proper capacity for residential and institutional services
while emphasizing serving customers in the community.
    As part of the Strategy development process, by January 1,
2022 the Department of Healthcare and Family Services shall
establish a program for the implementation of certified
community behavioral health clinics. Behavioral health
services providers that received federal grant funding from
SAMHSA for the implementation of certified community
behavioral health clinics prior to July 1, 2021 shall be
eligible to participate in the program established in
accordance with this Section.
 
Article 5.

 
    Section 5-5. The Illinois Public Aid Code is amended by
changing Section 5-5f and by adding Section 5-41 as follows:
 
    (305 ILCS 5/5-5f)
    Sec. 5-5f. Elimination and limitations of medical
assistance services. Notwithstanding any other provision of
this Code to the contrary, on and after July 1, 2012:
        (a) The following services shall no longer be a
    covered service available under this Code: group
    psychotherapy for residents of any facility licensed under
    the Nursing Home Care Act or the Specialized Mental Health
    Rehabilitation Act of 2013; and adult chiropractic
    services.
        (b) The Department shall place the following
    limitations on services: (i) the Department shall limit
    adult eyeglasses to one pair every 2 years; however, the
    limitation does not apply to an individual who needs
    different eyeglasses following a surgical procedure such
    as cataract surgery; (ii) the Department shall set an
    annual limit of a maximum of 20 visits for each of the
    following services: adult speech, hearing, and language
    therapy services, adult occupational therapy services, and
    physical therapy services; on or after October 1, 2014,
    the annual maximum limit of 20 visits shall expire but the
    Department may require prior approval for all individuals
    for speech, hearing, and language therapy services,
    occupational therapy services, and physical therapy
    services; (iii) the Department shall limit adult podiatry
    services to individuals with diabetes; on or after October
    1, 2014, podiatry services shall not be limited to
    individuals with diabetes; (iv) the Department shall pay
    for caesarean sections at the normal vaginal delivery rate
    unless a caesarean section was medically necessary; (v)
    the Department shall limit adult dental services to
    emergencies; beginning July 1, 2013, the Department shall
    ensure that the following conditions are recognized as
    emergencies: (A) dental services necessary for an
    individual in order for the individual to be cleared for a
    medical procedure, such as a transplant; (B) extractions
    and dentures necessary for a diabetic to receive proper
    nutrition; (C) extractions and dentures necessary as a
    result of cancer treatment; and (D) dental services
    necessary for the health of a pregnant woman prior to
    delivery of her baby; on or after July 1, 2014, adult
    dental services shall no longer be limited to emergencies,
    and dental services necessary for the health of a pregnant
    woman prior to delivery of her baby shall continue to be
    covered; and (vi) effective July 1, 2012 through June 30,
    2021, the Department shall place limitations and require
    concurrent review on every inpatient detoxification stay
    to prevent repeat admissions to any hospital for
    detoxification within 60 days of a previous inpatient
    detoxification stay. The Department shall convene a
    workgroup of hospitals, substance abuse providers, care
    coordination entities, managed care plans, and other
    stakeholders to develop recommendations for quality
    standards, diversion to other settings, and admission
    criteria for patients who need inpatient detoxification,
    which shall be published on the Department's website no
    later than September 1, 2013.
        (c) The Department shall require prior approval of the
    following services: wheelchair repairs costing more than
    $400, coronary artery bypass graft, and bariatric surgery
    consistent with Medicare standards concerning patient
    responsibility. Wheelchair repair prior approval requests
    shall be adjudicated within one business day of receipt of
    complete supporting documentation. Providers may not break
    wheelchair repairs into separate claims for purposes of
    staying under the $400 threshold for requiring prior
    approval. The wholesale price of manual and power
    wheelchairs, durable medical equipment and supplies, and
    complex rehabilitation technology products and services
    shall be defined as actual acquisition cost including all
    discounts.
        (d) The Department shall establish benchmarks for
    hospitals to measure and align payments to reduce
    potentially preventable hospital readmissions, inpatient
    complications, and unnecessary emergency room visits. In
    doing so, the Department shall consider items, including,
    but not limited to, historic and current acuity of care
    and historic and current trends in readmission. The
    Department shall publish provider-specific historical
    readmission data and anticipated potentially preventable
    targets 60 days prior to the start of the program. In the
    instance of readmissions, the Department shall adopt
    policies and rates of reimbursement for services and other
    payments provided under this Code to ensure that, by June
    30, 2013, expenditures to hospitals are reduced by, at a
    minimum, $40,000,000.
        (e) The Department shall establish utilization
    controls for the hospice program such that it shall not
    pay for other care services when an individual is in
    hospice.
        (f) For home health services, the Department shall
    require Medicare certification of providers participating
    in the program and implement the Medicare face-to-face
    encounter rule. The Department shall require providers to
    implement auditable electronic service verification based
    on global positioning systems or other cost-effective
    technology.
        (g) For the Home Services Program operated by the
    Department of Human Services and the Community Care
    Program operated by the Department on Aging, the
    Department of Human Services, in cooperation with the
    Department on Aging, shall implement an electronic service
    verification based on global positioning systems or other
    cost-effective technology.
        (h) Effective with inpatient hospital admissions on or
    after July 1, 2012, the Department shall reduce the
    payment for a claim that indicates the occurrence of a
    provider-preventable condition during the admission as
    specified by the Department in rules. The Department shall
    not pay for services related to an other
    provider-preventable condition.
        As used in this subsection (h):
        "Provider-preventable condition" means a health care
    acquired condition as defined under the federal Medicaid
    regulation found at 42 CFR 447.26 or an other
    provider-preventable condition.
        "Other provider-preventable condition" means a wrong
    surgical or other invasive procedure performed on a
    patient, a surgical or other invasive procedure performed
    on the wrong body part, or a surgical procedure or other
    invasive procedure performed on the wrong patient.
        (i) The Department shall implement cost savings
    initiatives for advanced imaging services, cardiac imaging
    services, pain management services, and back surgery. Such
    initiatives shall be designed to achieve annual costs
    savings.
        (j) The Department shall ensure that beneficiaries
    with a diagnosis of epilepsy or seizure disorder in
    Department records will not require prior approval for
    anticonvulsants.
(Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
 
    (305 ILCS 5/5-41 new)
    Sec. 5-41. Inpatient hospitalization for opioid-related
overdose or withdrawal patients. Due to the disproportionately
high opioid-related fatality rates among African Americans in
under-resourced communities in Illinois, the lack of community
resources, the comorbidities experienced by these patients,
and the high rate of hospital inpatient recidivism associated
with this population when improperly treated, the Department
shall ensure that patients, whether enrolled under the Medical
Assistance Fee For Service program or enrolled with a Medicaid
Managed Care Organization, experiencing opioid-related
overdose or withdrawal are admitted on an inpatient status and
the provider shall be reimbursed accordingly, when deemed
medically necessary, as determined by either the patient's
primary care physician, or the physician or other practitioner
responsible for the patient's care at the hospital to which
the patient presents, using criteria established by the
American Society of Addiction Medicine. If it is determined by
the physician or other practitioner responsible for the
patient's care at the hospital to which the patient presents,
that a patient does not meet medical necessity criteria for
the admission, then the patient may be treated via observation
and the provider shall seek reimbursement accordingly. Nothing
in this Section shall diminish the requirements of a provider
to document medical necessity in the patient's record.
 
Article 10.

 
    Section 10-5. The Illinois Public Aid Code is amended by
changing Section 5-8 as follows:
 
    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
    Sec. 5-8. Practitioners. In supplying medical assistance,
the Illinois Department may provide for the legally authorized
services of (i) persons licensed under the Medical Practice
Act of 1987, as amended, except as hereafter in this Section
stated, whether under a general or limited license, (ii)
persons licensed under the Nurse Practice Act as advanced
practice registered nurses, regardless of whether or not the
persons have written collaborative agreements, (iii) persons
licensed or registered under other laws of this State to
provide dental, medical, pharmaceutical, optometric,
podiatric, or nursing services, or other remedial care
recognized under State law, (iv) persons licensed under other
laws of this State as a clinical social worker, and (v) persons
licensed under other laws of this State as physician
assistants. The Department shall adopt rules, no later than 90
days after January 1, 2017 (the effective date of Public Act
99-621), for the legally authorized services of persons
licensed under other laws of this State as a clinical social
worker. The Department shall provide for the legally
authorized services of persons licensed under the Professional
Counselor and Clinical Professional Counselor Licensing and
Practice Act as clinical professional counselors and for the
legally authorized services of persons licensed under the
Marriage and Family Therapy Licensing Act as marriage and
family therapists. The utilization of the services of persons
engaged in the treatment or care of the sick, which persons are
not required to be licensed or registered under the laws of
this State, is not prohibited by this Section.
(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff.
1-1-18; 100-863, eff. 8-14-18.)
 
Article 15.

 
    Section 15-5. The Department of Healthcare and Family
Services Law of the Civil Administrative Code of Illinois is
amended by adding Section 2205-35 as follows:
 
    (20 ILCS 2205/2205-35 new)
    Sec. 2205-35. Certified veteran support specialists. The
Department of Healthcare and Family Services shall recognize
veteran support specialists who are certified by, and in good
standing with, the Illinois Alcohol and Other Drug Abuse
Professional Certification Association, Inc. as mental health
professionals as defined in the Illinois Title XIX State Plan
and in 89 Ill. Adm. Code 140.453.
 
Article 20.

 
    Section 20-5. The Illinois Public Aid Code is amended by
adding Section 5-5.4k as follows:
 
    (305 ILCS 5/5-5.4k new)
    Sec. 5-5.4k. Payments for long-acting injectable
medications for mental health or substance use disorders.
Notwithstanding any other provision of this Code, effective
for dates of service on and after January 1, 2022, the medical
assistance program shall separately reimburse at the
prevailing fee schedule, for long-acting injectable
medications administered for mental health or substance use
disorder in the hospital inpatient setting, and which are
compliant with the prior authorization requirements of this
Section. The Department, in consultation with a statewide
association representing a majority of hospitals and Managed
Care Organizations shall implement, by rule, reimbursement
policy and prior authorization criteria for the use of
long-acting injectable medications administered in the
hospital inpatient setting for the treatment of mental health
disorders.
 
Article 25.

 
    Section 25-3. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.8 as follows:
 
    (5 ILCS 100/5-45.8 new)
    Sec. 5-45.8. Emergency rulemaking; Medicaid eligibility
expansion. To provide for the expeditious and timely
implementation of the changes made to paragraph 6 of Section
5-2 of the Illinois Public Aid Code by this amendatory Act of
the 102nd General Assembly, emergency rules implementing the
changes made to paragraph 6 of Section 5-2 of the Illinois
Public Aid Code by this amendatory Act of the 102nd General
Assembly may be adopted in accordance with Section 5-45 by the
Department of Healthcare and Family Services. The adoption of
emergency rules authorized by Section 5-45 and this Section is
deemed to be necessary for the public interest, safety, and
welfare.
    This Section is repealed on January 1, 2027.
 
    Section 25-5. The Children's Health Insurance Program Act
is amended by adding Section 6 as follows:
 
    (215 ILCS 106/6 new)
    Sec. 6. Act inoperative. This Act is inoperative if (i)
the Department of Healthcare and Family Services receives
federal approval to make children younger than 19 who have
countable income at or below 313% of the federal poverty level
eligible for medical assistance under Article V of the
Illinois Public Aid Code and (ii) the Department, upon federal
approval, transitions children eligible for health care
benefits under this Act into the medical assistance program
established under Article V of the Illinois Public Aid Code.
 
    Section 25-10. The Covering ALL KIDS Health Insurance Act
is amended by adding Section 6 as follows:
 
    (215 ILCS 170/6 new)
    Sec. 6. Act inoperative. This Act is inoperative if (i)
the Department of Healthcare and Family Services receives
federal approval to make children younger than 19 who have
countable income at or below 313% of the federal poverty level
eligible for medical assistance under Article V of the
Illinois Public Aid Code and (ii) the Department, upon federal
approval, transitions children eligible for health care
benefits under this Act into the medical assistance program
established under Article V of the Illinois Public Aid Code.
 
    Section 25-15. The Illinois Public Aid Code is amended by
changing Sections 5-1.5, 5-2, and 12-4.35, and by adding
Sections 11-4.2, 11-22d, and 11-32 as follows:
 
    (305 ILCS 5/5-1.5)
    Sec. 5-1.5. COVID-19 public health emergency.
Notwithstanding any other provision of Articles V, XI, and XII
of this Code, the Department may take necessary actions to
address the COVID-19 public health emergency to the extent
such actions are required, approved, or authorized by the
United States Department of Health and Human Services, Centers
for Medicare and Medicaid Services. Such actions may continue
throughout the public health emergency and for up to 12 months
after the period ends, and may include, but are not limited to:
accepting an applicant's or recipient's attestation of income,
incurred medical expenses, residency, and insured status when
electronic verification is not available; eliminating resource
tests for some eligibility determinations; suspending
redeterminations; suspending changes that would adversely
affect an applicant's or recipient's eligibility; phone or
verbal approval by an applicant to submit an application in
lieu of applicant signature; allowing adult presumptive
eligibility; allowing presumptive eligibility for children,
pregnant women, and adults as often as twice per calendar
year; paying for additional services delivered by telehealth;
and suspending premium and co-payment requirements.
    The Department's authority under this Section shall only
extend to encompass, incorporate, or effectuate the terms,
items, conditions, and other provisions approved, authorized,
or required by the United States Department of Health and
Human Services, Centers for Medicare and Medicaid Services,
and shall not extend beyond the time of the COVID-19 public
health emergency and up to 12 months after the period expires.
    Any individual determined eligible for medical assistance
under this Code as of or during the COVID-19 public health
emergency may be treated as eligible for such medical
assistance benefits during the COVID-19 public health
emergency, and up to 12 months after the period expires,
regardless of whether federally required or whether the
individual's eligibility may be State or federally funded,
unless the individual requests a voluntary termination of
eligibility or ceases to be a resident. This paragraph shall
not restrict any determination of medical need or
appropriateness for any particular service and shall not
require continued coverage of any particular service that may
be no longer necessary, appropriate, or otherwise authorized
for an individual. Nothing shall prevent the Department from
determining and properly establishing an individual's
eligibility under a different category of eligibility.
(Source: P.A. 101-649, eff. 7-7-20.)
 
    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
    Sec. 5-2. Classes of persons eligible. Medical assistance
under this Article shall be available to any of the following
classes of persons in respect to whom a plan for coverage has
been submitted to the Governor by the Illinois Department and
approved by him. If changes made in this Section 5-2 require
federal approval, they shall not take effect until such
approval has been received:
        1. Recipients of basic maintenance grants under
    Articles III and IV.
        2. Beginning January 1, 2014, persons otherwise
    eligible for basic maintenance under Article III,
    excluding any eligibility requirements that are
    inconsistent with any federal law or federal regulation,
    as interpreted by the U.S. Department of Health and Human
    Services, but who fail to qualify thereunder on the basis
    of need, and who have insufficient income and resources to
    meet the costs of necessary medical care, including, but
    not limited to, the following:
            (a) All persons otherwise eligible for basic
        maintenance under Article III but who fail to qualify
        under that Article on the basis of need and who meet
        either of the following requirements:
                (i) their income, as determined by the
            Illinois Department in accordance with any federal
            requirements, is equal to or less than 100% of the
            federal poverty level; or
                (ii) their income, after the deduction of
            costs incurred for medical care and for other
            types of remedial care, is equal to or less than
            100% of the federal poverty level.
            (b) (Blank).
        3. (Blank).
        4. Persons not eligible under any of the preceding
    paragraphs who fall sick, are injured, or die, not having
    sufficient money, property or other resources to meet the
    costs of necessary medical care or funeral and burial
    expenses.
        5.(a) Beginning January 1, 2020, women during
    pregnancy and during the 12-month period beginning on the
    last day of the pregnancy, together with their infants,
    whose income is at or below 200% of the federal poverty
    level. Until September 30, 2019, or sooner if the
    maintenance of effort requirements under the Patient
    Protection and Affordable Care Act are eliminated or may
    be waived before then, women during pregnancy and during
    the 12-month period beginning on the last day of the
    pregnancy, whose countable monthly income, after the
    deduction of costs incurred for medical care and for other
    types of remedial care as specified in administrative
    rule, is equal to or less than the Medical Assistance-No
    Grant(C) (MANG(C)) Income Standard in effect on April 1,
    2013 as set forth in administrative rule.
        (b) The plan for coverage shall provide ambulatory
    prenatal care to pregnant women during a presumptive
    eligibility period and establish an income eligibility
    standard that is equal to 200% of the federal poverty
    level, provided that costs incurred for medical care are
    not taken into account in determining such income
    eligibility.
        (c) The Illinois Department may conduct a
    demonstration in at least one county that will provide
    medical assistance to pregnant women, together with their
    infants and children up to one year of age, where the
    income eligibility standard is set up to 185% of the
    nonfarm income official poverty line, as defined by the
    federal Office of Management and Budget. The Illinois
    Department shall seek and obtain necessary authorization
    provided under federal law to implement such a
    demonstration. Such demonstration may establish resource
    standards that are not more restrictive than those
    established under Article IV of this Code.
        6. (a) Subject to federal approval, children Children
    younger than age 19 when countable income is at or below
    313% 133% of the federal poverty level, as determined by
    the Department and in accordance with all applicable
    federal requirements. The Department is authorized to
    adopt emergency rules to implement the changes made to
    this paragraph by this amendatory Act of the 102nd General
    Assembly. Until September 30, 2019, or sooner if the
    maintenance of effort requirements under the Patient
    Protection and Affordable Care Act are eliminated or may
    be waived before then, children younger than age 19 whose
    countable monthly income, after the deduction of costs
    incurred for medical care and for other types of remedial
    care as specified in administrative rule, is equal to or
    less than the Medical Assistance-No Grant(C) (MANG(C))
    Income Standard in effect on April 1, 2013 as set forth in
    administrative rule.
        (b) Children and youth who are under temporary custody
    or guardianship of the Department of Children and Family
    Services or who receive financial assistance in support of
    an adoption or guardianship placement from the Department
    of Children and Family Services.
        7. (Blank).
        8. As required under federal law, persons who are
    eligible for Transitional Medical Assistance as a result
    of an increase in earnings or child or spousal support
    received. The plan for coverage for this class of persons
    shall:
            (a) extend the medical assistance coverage to the
        extent required by federal law; and
            (b) offer persons who have initially received 6
        months of the coverage provided in paragraph (a)
        above, the option of receiving an additional 6 months
        of coverage, subject to the following:
                (i) such coverage shall be pursuant to
            provisions of the federal Social Security Act;
                (ii) such coverage shall include all services
            covered under Illinois' State Medicaid Plan;
                (iii) no premium shall be charged for such
            coverage; and
                (iv) such coverage shall be suspended in the
            event of a person's failure without good cause to
            file in a timely fashion reports required for this
            coverage under the Social Security Act and
            coverage shall be reinstated upon the filing of
            such reports if the person remains otherwise
            eligible.
        9. Persons with acquired immunodeficiency syndrome
    (AIDS) or with AIDS-related conditions with respect to
    whom there has been a determination that but for home or
    community-based services such individuals would require
    the level of care provided in an inpatient hospital,
    skilled nursing facility or intermediate care facility the
    cost of which is reimbursed under this Article. Assistance
    shall be provided to such persons to the maximum extent
    permitted under Title XIX of the Federal Social Security
    Act.
        10. Participants in the long-term care insurance
    partnership program established under the Illinois
    Long-Term Care Partnership Program Act who meet the
    qualifications for protection of resources described in
    Section 15 of that Act.
        11. Persons with disabilities who are employed and
    eligible for Medicaid, pursuant to Section
    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
    subject to federal approval, persons with a medically
    improved disability who are employed and eligible for
    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
    the Social Security Act, as provided by the Illinois
    Department by rule. In establishing eligibility standards
    under this paragraph 11, the Department shall, subject to
    federal approval:
            (a) set the income eligibility standard at not
        lower than 350% of the federal poverty level;
            (b) exempt retirement accounts that the person
        cannot access without penalty before the age of 59
        1/2, and medical savings accounts established pursuant
        to 26 U.S.C. 220;
            (c) allow non-exempt assets up to $25,000 as to
        those assets accumulated during periods of eligibility
        under this paragraph 11; and
            (d) continue to apply subparagraphs (b) and (c) in
        determining the eligibility of the person under this
        Article even if the person loses eligibility under
        this paragraph 11.
        12. Subject to federal approval, persons who are
    eligible for medical assistance coverage under applicable
    provisions of the federal Social Security Act and the
    federal Breast and Cervical Cancer Prevention and
    Treatment Act of 2000. Those eligible persons are defined
    to include, but not be limited to, the following persons:
            (1) persons who have been screened for breast or
        cervical cancer under the U.S. Centers for Disease
        Control and Prevention Breast and Cervical Cancer
        Program established under Title XV of the federal
        Public Health Service Services Act in accordance with
        the requirements of Section 1504 of that Act as
        administered by the Illinois Department of Public
        Health; and
            (2) persons whose screenings under the above
        program were funded in whole or in part by funds
        appropriated to the Illinois Department of Public
        Health for breast or cervical cancer screening.
        "Medical assistance" under this paragraph 12 shall be
    identical to the benefits provided under the State's
    approved plan under Title XIX of the Social Security Act.
    The Department must request federal approval of the
    coverage under this paragraph 12 within 30 days after July
    3, 2001 (the effective date of Public Act 92-47) this
    amendatory Act of the 92nd General Assembly.
        In addition to the persons who are eligible for
    medical assistance pursuant to subparagraphs (1) and (2)
    of this paragraph 12, and to be paid from funds
    appropriated to the Department for its medical programs,
    any uninsured person as defined by the Department in rules
    residing in Illinois who is younger than 65 years of age,
    who has been screened for breast and cervical cancer in
    accordance with standards and procedures adopted by the
    Department of Public Health for screening, and who is
    referred to the Department by the Department of Public
    Health as being in need of treatment for breast or
    cervical cancer is eligible for medical assistance
    benefits that are consistent with the benefits provided to
    those persons described in subparagraphs (1) and (2).
    Medical assistance coverage for the persons who are
    eligible under the preceding sentence is not dependent on
    federal approval, but federal moneys may be used to pay
    for services provided under that coverage upon federal
    approval.
        13. Subject to appropriation and to federal approval,
    persons living with HIV/AIDS who are not otherwise
    eligible under this Article and who qualify for services
    covered under Section 5-5.04 as provided by the Illinois
    Department by rule.
        14. Subject to the availability of funds for this
    purpose, the Department may provide coverage under this
    Article to persons who reside in Illinois who are not
    eligible under any of the preceding paragraphs and who
    meet the income guidelines of paragraph 2(a) of this
    Section and (i) have an application for asylum pending
    before the federal Department of Homeland Security or on
    appeal before a court of competent jurisdiction and are
    represented either by counsel or by an advocate accredited
    by the federal Department of Homeland Security and
    employed by a not-for-profit organization in regard to
    that application or appeal, or (ii) are receiving services
    through a federally funded torture treatment center.
    Medical coverage under this paragraph 14 may be provided
    for up to 24 continuous months from the initial
    eligibility date so long as an individual continues to
    satisfy the criteria of this paragraph 14. If an
    individual has an appeal pending regarding an application
    for asylum before the Department of Homeland Security,
    eligibility under this paragraph 14 may be extended until
    a final decision is rendered on the appeal. The Department
    may adopt rules governing the implementation of this
    paragraph 14.
        15. Family Care Eligibility.
            (a) On and after July 1, 2012, a parent or other
        caretaker relative who is 19 years of age or older when
        countable income is at or below 133% of the federal
        poverty level. A person may not spend down to become
        eligible under this paragraph 15.
            (b) Eligibility shall be reviewed annually.
            (c) (Blank).
            (d) (Blank).
            (e) (Blank).
            (f) (Blank).
            (g) (Blank).
            (h) (Blank).
            (i) Following termination of an individual's
        coverage under this paragraph 15, the individual must
        be determined eligible before the person can be
        re-enrolled.
        16. Subject to appropriation, uninsured persons who
    are not otherwise eligible under this Section who have
    been certified and referred by the Department of Public
    Health as having been screened and found to need
    diagnostic evaluation or treatment, or both diagnostic
    evaluation and treatment, for prostate or testicular
    cancer. For the purposes of this paragraph 16, uninsured
    persons are those who do not have creditable coverage, as
    defined under the Health Insurance Portability and
    Accountability Act, or have otherwise exhausted any
    insurance benefits they may have had, for prostate or
    testicular cancer diagnostic evaluation or treatment, or
    both diagnostic evaluation and treatment. To be eligible,
    a person must furnish a Social Security number. A person's
    assets are exempt from consideration in determining
    eligibility under this paragraph 16. Such persons shall be
    eligible for medical assistance under this paragraph 16
    for so long as they need treatment for the cancer. A person
    shall be considered to need treatment if, in the opinion
    of the person's treating physician, the person requires
    therapy directed toward cure or palliation of prostate or
    testicular cancer, including recurrent metastatic cancer
    that is a known or presumed complication of prostate or
    testicular cancer and complications resulting from the
    treatment modalities themselves. Persons who require only
    routine monitoring services are not considered to need
    treatment. "Medical assistance" under this paragraph 16
    shall be identical to the benefits provided under the
    State's approved plan under Title XIX of the Social
    Security Act. Notwithstanding any other provision of law,
    the Department (i) does not have a claim against the
    estate of a deceased recipient of services under this
    paragraph 16 and (ii) does not have a lien against any
    homestead property or other legal or equitable real
    property interest owned by a recipient of services under
    this paragraph 16.
        17. Persons who, pursuant to a waiver approved by the
    Secretary of the U.S. Department of Health and Human
    Services, are eligible for medical assistance under Title
    XIX or XXI of the federal Social Security Act.
    Notwithstanding any other provision of this Code and
    consistent with the terms of the approved waiver, the
    Illinois Department, may by rule:
            (a) Limit the geographic areas in which the waiver
        program operates.
            (b) Determine the scope, quantity, duration, and
        quality, and the rate and method of reimbursement, of
        the medical services to be provided, which may differ
        from those for other classes of persons eligible for
        assistance under this Article.
            (c) Restrict the persons' freedom in choice of
        providers.
        18. Beginning January 1, 2014, persons aged 19 or
    older, but younger than 65, who are not otherwise eligible
    for medical assistance under this Section 5-2, who qualify
    for medical assistance pursuant to 42 U.S.C.
    1396a(a)(10)(A)(i)(VIII) and applicable federal
    regulations, and who have income at or below 133% of the
    federal poverty level plus 5% for the applicable family
    size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
    applicable federal regulations. Persons eligible for
    medical assistance under this paragraph 18 shall receive
    coverage for the Health Benefits Service Package as that
    term is defined in subsection (m) of Section 5-1.1 of this
    Code. If Illinois' federal medical assistance percentage
    (FMAP) is reduced below 90% for persons eligible for
    medical assistance under this paragraph 18, eligibility
    under this paragraph 18 shall cease no later than the end
    of the third month following the month in which the
    reduction in FMAP takes effect.
        19. Beginning January 1, 2014, as required under 42
    U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
    and younger than age 26 who are not otherwise eligible for
    medical assistance under paragraphs (1) through (17) of
    this Section who (i) were in foster care under the
    responsibility of the State on the date of attaining age
    18 or on the date of attaining age 21 when a court has
    continued wardship for good cause as provided in Section
    2-31 of the Juvenile Court Act of 1987 and (ii) received
    medical assistance under the Illinois Title XIX State Plan
    or waiver of such plan while in foster care.
        20. Beginning January 1, 2018, persons who are
    foreign-born victims of human trafficking, torture, or
    other serious crimes as defined in Section 2-19 of this
    Code and their derivative family members if such persons:
    (i) reside in Illinois; (ii) are not eligible under any of
    the preceding paragraphs; (iii) meet the income guidelines
    of subparagraph (a) of paragraph 2; and (iv) meet the
    nonfinancial eligibility requirements of Sections 16-2,
    16-3, and 16-5 of this Code. The Department may extend
    medical assistance for persons who are foreign-born
    victims of human trafficking, torture, or other serious
    crimes whose medical assistance would be terminated
    pursuant to subsection (b) of Section 16-5 if the
    Department determines that the person, during the year of
    initial eligibility (1) experienced a health crisis, (2)
    has been unable, after reasonable attempts, to obtain
    necessary information from a third party, or (3) has other
    extenuating circumstances that prevented the person from
    completing his or her application for status. The
    Department may adopt any rules necessary to implement the
    provisions of this paragraph.
        21. Persons who are not otherwise eligible for medical
    assistance under this Section who may qualify for medical
    assistance pursuant to 42 U.S.C.
    1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
    duration of any federal or State declared emergency due to
    COVID-19. Medical assistance to persons eligible for
    medical assistance solely pursuant to this paragraph 21
    shall be limited to any in vitro diagnostic product (and
    the administration of such product) described in 42 U.S.C.
    1396d(a)(3)(B) on or after March 18, 2020, any visit
    described in 42 U.S.C. 1396o(a)(2)(G), or any other
    medical assistance that may be federally authorized for
    this class of persons. The Department may also cover
    treatment of COVID-19 for this class of persons, or any
    similar category of uninsured individuals, to the extent
    authorized under a federally approved 1115 Waiver or other
    federal authority. Notwithstanding the provisions of
    Section 1-11 of this Code, due to the nature of the
    COVID-19 public health emergency, the Department may cover
    and provide the medical assistance described in this
    paragraph 21 to noncitizens who would otherwise meet the
    eligibility requirements for the class of persons
    described in this paragraph 21 for the duration of the
    State emergency period.
    In implementing the provisions of Public Act 96-20, the
Department is authorized to adopt only those rules necessary,
including emergency rules. Nothing in Public Act 96-20 permits
the Department to adopt rules or issue a decision that expands
eligibility for the FamilyCare Program to a person whose
income exceeds 185% of the Federal Poverty Level as determined
from time to time by the U.S. Department of Health and Human
Services, unless the Department is provided with express
statutory authority.
    The eligibility of any such person for medical assistance
under this Article is not affected by the payment of any grant
under the Senior Citizens and Persons with Disabilities
Property Tax Relief Act or any distributions or items of
income described under subparagraph (X) of paragraph (2) of
subsection (a) of Section 203 of the Illinois Income Tax Act.
    The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for
medical assistance, which shall at a minimum equal the amounts
to be disregarded under the Federal Supplemental Security
Income Program. The amount of assets of a single person to be
disregarded shall not be less than $2,000, and the amount of
assets of a married couple to be disregarded shall not be less
than $3,000.
    To the extent permitted under federal law, any person
found guilty of a second violation of Article VIIIA shall be
ineligible for medical assistance under this Article, as
provided in Section 8A-8.
    The eligibility of any person for medical assistance under
this Article shall not be affected by the receipt by the person
of donations or benefits from fundraisers held for the person
in cases of serious illness, as long as neither the person nor
members of the person's family have actual control over the
donations or benefits or the disbursement of the donations or
benefits.
    Notwithstanding any other provision of this Code, if the
United States Supreme Court holds Title II, Subtitle A,
Section 2001(a) of Public Law 111-148 to be unconstitutional,
or if a holding of Public Law 111-148 makes Medicaid
eligibility allowed under Section 2001(a) inoperable, the
State or a unit of local government shall be prohibited from
enrolling individuals in the Medical Assistance Program as the
result of federal approval of a State Medicaid waiver on or
after June 14, 2012 (the effective date of Public Act 97-687)
this amendatory Act of the 97th General Assembly, and any
individuals enrolled in the Medical Assistance Program
pursuant to eligibility permitted as a result of such a State
Medicaid waiver shall become immediately ineligible.
    Notwithstanding any other provision of this Code, if an
Act of Congress that becomes a Public Law eliminates Section
2001(a) of Public Law 111-148, the State or a unit of local
government shall be prohibited from enrolling individuals in
the Medical Assistance Program as the result of federal
approval of a State Medicaid waiver on or after June 14, 2012
(the effective date of Public Act 97-687) this amendatory Act
of the 97th General Assembly, and any individuals enrolled in
the Medical Assistance Program pursuant to eligibility
permitted as a result of such a State Medicaid waiver shall
become immediately ineligible.
    Effective October 1, 2013, the determination of
eligibility of persons who qualify under paragraphs 5, 6, 8,
15, 17, and 18 of this Section shall comply with the
requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
regulations.
    The Department of Healthcare and Family Services, the
Department of Human Services, and the Illinois health
insurance marketplace shall work cooperatively to assist
persons who would otherwise lose health benefits as a result
of changes made under Public Act 98-104 this amendatory Act of
the 98th General Assembly to transition to other health
insurance coverage.
(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
revised 8-24-20.)
 
    (305 ILCS 5/11-4.2 new)
    Sec. 11-4.2. Application assistance for enrolling
individuals in the medical assistance program.
    (a) The Department shall have procedures to allow
application agents to assist in enrolling individuals in the
medical assistance program. As used in this Section,
"application agent" means an organization or individual, such
as a licensed health care provider, school, youth service
agency, employer, labor union, local chamber of commerce,
community-based organization, or other organization, approved
by the Department to assist in enrolling individuals in the
medical assistance program.
    (b) At the Department's discretion, technical assistance
payments may be made available for approved applications
facilitated by an application agent. The Department shall
permit day and temporary labor service agencies, as defined in
the Day and Temporary Labor Services Act, doing business in
Illinois to enroll as unpaid application agents. As
established in the Free Healthcare Benefits Application
Assistance Act, it shall be unlawful for any person to charge
another person or family for assisting in completing and
submitting an application for enrollment in the medical
assistance program.
    (c) Existing enrollment agreements or contracts for all
application agents, technical assistance payments, and
outreach grants that were authorized under Section 22 of the
Children's Health Insurance Program Act and Sections 25 and 30
of the Covering ALL KIDS Health Insurance Act prior to those
Acts becoming inoperative shall continue to be authorized
under this Section per the terms of the agreement or contract
until modified, amended, or terminated.
 
    (305 ILCS 5/11-22d new)
    Sec. 11-22d. Savings provisions.
    (a) Notwithstanding any amendments or provisions in this
amendatory Act of the 102nd General Assembly which would make
the Children's Health Insurance Program Act or the Covering
ALL KIDS Health Insurance Act inoperative, Sections 11-22a,
11-22b, and 11-22c of this Code shall remain in force for the
commencement or continuation of any cause of action that (i)
accrued prior to the effective date of this amendatory Act of
the 102nd General Assembly or the date upon which the
Department receives federal approval of the changes made to
paragraph (6) of Section 5-2 by this amendatory Act of the
102nd General Assembly, whichever is later, and (ii) concerns
the recovery of any amount expended by the State for health
care benefits provided under the Children's Health Insurance
Program Act or the Covering ALL KIDS Health Insurance Act
prior to those Acts becoming inoperative. Any timely action
brought under Sections 11-22a, 11-22b, and 11-22c shall be
decided in accordance with those Sections as they existed when
the cause of action accrued.
    (b) Notwithstanding any amendments or provisions in this
amendatory Act of the 102nd General Assembly which would make
the Children's Health Insurance Program Act or the Covering
ALL KIDS Health Insurance Act inoperative, paragraph (2) of
Section 12-9 of this Code shall remain in force as to
recoveries made by the Department of Healthcare and Family
Services from any cause of action commenced or continued in
accordance with subsection (a).
 
    (305 ILCS 5/11-32 new)
    Sec. 11-32. Premium debts; forgiveness, compromise,
reduction. The Department may forgive, compromise, or reduce
any debt owed by a former or current recipient of medical
assistance under this Code or health care benefits under the
Children's Health Insurance Program or the Covering ALL KIDS
Health Insurance Program that is related to any premium that
was determined or imposed in accordance with (i) the
Children's Health Insurance Program Act or the Covering ALL
KIDS Health Insurance Act prior to those Acts becoming
inoperative or (ii) any corresponding administrative rule.
 
    (305 ILCS 5/12-4.35)
    Sec. 12-4.35. Medical services for certain noncitizens.
    (a) Notwithstanding Section 1-11 of this Code or Section
20(a) of the Children's Health Insurance Program Act, the
Department of Healthcare and Family Services may provide
medical services to noncitizens who have not yet attained 19
years of age and who are not eligible for medical assistance
under Article V of this Code or under the Children's Health
Insurance Program created by the Children's Health Insurance
Program Act due to their not meeting the otherwise applicable
provisions of Section 1-11 of this Code or Section 20(a) of the
Children's Health Insurance Program Act. The medical services
available, standards for eligibility, and other conditions of
participation under this Section shall be established by rule
by the Department; however, any such rule shall be at least as
restrictive as the rules for medical assistance under Article
V of this Code or the Children's Health Insurance Program
created by the Children's Health Insurance Program Act.
    (a-5) Notwithstanding Section 1-11 of this Code, the
Department of Healthcare and Family Services may provide
medical assistance in accordance with Article V of this Code
to noncitizens over the age of 65 years of age who are not
eligible for medical assistance under Article V of this Code
due to their not meeting the otherwise applicable provisions
of Section 1-11 of this Code, whose income is at or below 100%
of the federal poverty level after deducting the costs of
medical or other remedial care, and who would otherwise meet
the eligibility requirements in Section 5-2 of this Code. The
medical services available, standards for eligibility, and
other conditions of participation under this Section shall be
established by rule by the Department; however, any such rule
shall be at least as restrictive as the rules for medical
assistance under Article V of this Code.
    (b) The Department is authorized to take any action that
would not otherwise be prohibited by applicable law, including
without limitation cessation or limitation of enrollment,
reduction of available medical services, and changing
standards for eligibility, that is deemed necessary by the
Department during a State fiscal year to assure that payments
under this Section do not exceed available funds.
    (c) (Blank). Continued enrollment of individuals into the
program created under subsection (a) of this Section in any
fiscal year is contingent upon continued enrollment of
individuals into the Children's Health Insurance Program
during that fiscal year.
    (d) (Blank).
(Source: P.A. 101-636, eff. 6-10-20.)
 
Article 30.

 
    Section 30-5. The Illinois Public Aid Code is amended by
changing Sections 5-5 and 5-5f as follows:
 
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
    Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant women, provided by an individual licensed to
practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
    Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
    Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
    Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
    Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
    On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
        (1) dental services provided by or under the
    supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    the diseases of the eye, or by an optometrist, whichever
    the person may select.
    On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
    On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
    Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
    The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
    The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    age.
        (B) An annual mammogram for women 40 years of age or
    older.
        (C) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider
    for women under 40 years of age and having a family history
    of breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening and MRI of an
    entire breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue or when medically
    necessary as determined by a physician licensed to
    practice medicine in all of its branches.
        (E) A screening MRI when medically necessary, as
    determined by a physician licensed to practice medicine in
    all of its branches.
        (F) A diagnostic mammogram when medically necessary,
    as determined by a physician licensed to practice medicine
    in all its branches, advanced practice registered nurse,
    or physician assistant.
    The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
    All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
     For purposes of this Section:
    "Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
    "Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
    "Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
    "Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
    If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
    On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
    On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography.
    The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
    On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
    The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
    Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
    The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
    The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
    The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
    The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
    Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
    All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women in
addition to treatment for addiction.
    The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
    The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
    The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    providing certain services, which shall be determined by
    the Illinois Department, to persons in areas covered by
    the Partnership may receive an additional surcharge for
    such services.
        (2) The Department may elect to consider and negotiate
    financial incentives to encourage the development of
    Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    Partnerships may receive medical and case management
    services above the level usually offered through the
    medical assistance program.
    Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
    The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
    The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
    The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
    The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
    Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
    The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
    To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
        (1) In the case of a provider whose enrollment is in
    process by the Illinois Department, the 180-day period
    shall not begin until the date on the written notice from
    the Illinois Department that the provider enrollment is
    complete.
        (2) In the case of errors attributable to the Illinois
    Department or any of its claims processing intermediaries
    which result in an inability to receive, process, or
    adjudicate a claim, the 180-day period shall not begin
    until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    local government with a population exceeding 3,000,000
    when local government funds finance federal participation
    for claims payments.
    For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
    In the case of long term care facilities, within 45
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
    Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
    To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
    The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
    The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
    The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
    In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
    The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
    The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
    The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    Illinois Department.
    The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
    Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
    Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
    Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
    On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees related to the dispensing and administration of the
opioid antagonist, shall be covered under the medical
assistance program for persons who are otherwise eligible for
medical assistance under this Article. As used in this
Section, "opioid antagonist" means a drug that binds to opioid
receptors and blocks or inhibits the effect of opioids acting
on those receptors, including, but not limited to, naloxone
hydrochloride or any other similarly acting drug approved by
the U.S. Food and Drug Administration.
    Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
    A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
1-1-20; revised 9-18-19.)
 
    (305 ILCS 5/5-5f)
    Sec. 5-5f. Elimination and limitations of medical
assistance services. Notwithstanding any other provision of
this Code to the contrary, on and after July 1, 2012:
        (a) The following service services shall no longer be
    a covered service available under this Code: group
    psychotherapy for residents of any facility licensed under
    the Nursing Home Care Act or the Specialized Mental Health
    Rehabilitation Act of 2013; and adult chiropractic
    services.
        (b) The Department shall place the following
    limitations on services: (i) the Department shall limit
    adult eyeglasses to one pair every 2 years; however, the
    limitation does not apply to an individual who needs
    different eyeglasses following a surgical procedure such
    as cataract surgery; (ii) the Department shall set an
    annual limit of a maximum of 20 visits for each of the
    following services: adult speech, hearing, and language
    therapy services, adult occupational therapy services, and
    physical therapy services; on or after October 1, 2014,
    the annual maximum limit of 20 visits shall expire but the
    Department may require prior approval for all individuals
    for speech, hearing, and language therapy services,
    occupational therapy services, and physical therapy
    services; (iii) the Department shall limit adult podiatry
    services to individuals with diabetes; on or after October
    1, 2014, podiatry services shall not be limited to
    individuals with diabetes; (iv) the Department shall pay
    for caesarean sections at the normal vaginal delivery rate
    unless a caesarean section was medically necessary; (v)
    the Department shall limit adult dental services to
    emergencies; beginning July 1, 2013, the Department shall
    ensure that the following conditions are recognized as
    emergencies: (A) dental services necessary for an
    individual in order for the individual to be cleared for a
    medical procedure, such as a transplant; (B) extractions
    and dentures necessary for a diabetic to receive proper
    nutrition; (C) extractions and dentures necessary as a
    result of cancer treatment; and (D) dental services
    necessary for the health of a pregnant woman prior to
    delivery of her baby; on or after July 1, 2014, adult
    dental services shall no longer be limited to emergencies,
    and dental services necessary for the health of a pregnant
    woman prior to delivery of her baby shall continue to be
    covered; and (vi) effective July 1, 2012, the Department
    shall place limitations and require concurrent review on
    every inpatient detoxification stay to prevent repeat
    admissions to any hospital for detoxification within 60
    days of a previous inpatient detoxification stay. The
    Department shall convene a workgroup of hospitals,
    substance abuse providers, care coordination entities,
    managed care plans, and other stakeholders to develop
    recommendations for quality standards, diversion to other
    settings, and admission criteria for patients who need
    inpatient detoxification, which shall be published on the
    Department's website no later than September 1, 2013.
        (c) The Department shall require prior approval of the
    following services: wheelchair repairs costing more than
    $400, coronary artery bypass graft, and bariatric surgery
    consistent with Medicare standards concerning patient
    responsibility. Wheelchair repair prior approval requests
    shall be adjudicated within one business day of receipt of
    complete supporting documentation. Providers may not break
    wheelchair repairs into separate claims for purposes of
    staying under the $400 threshold for requiring prior
    approval. The wholesale price of manual and power
    wheelchairs, durable medical equipment and supplies, and
    complex rehabilitation technology products and services
    shall be defined as actual acquisition cost including all
    discounts.
        (d) The Department shall establish benchmarks for
    hospitals to measure and align payments to reduce
    potentially preventable hospital readmissions, inpatient
    complications, and unnecessary emergency room visits. In
    doing so, the Department shall consider items, including,
    but not limited to, historic and current acuity of care
    and historic and current trends in readmission. The
    Department shall publish provider-specific historical
    readmission data and anticipated potentially preventable
    targets 60 days prior to the start of the program. In the
    instance of readmissions, the Department shall adopt
    policies and rates of reimbursement for services and other
    payments provided under this Code to ensure that, by June
    30, 2013, expenditures to hospitals are reduced by, at a
    minimum, $40,000,000.
        (e) The Department shall establish utilization
    controls for the hospice program such that it shall not
    pay for other care services when an individual is in
    hospice.
        (f) For home health services, the Department shall
    require Medicare certification of providers participating
    in the program and implement the Medicare face-to-face
    encounter rule. The Department shall require providers to
    implement auditable electronic service verification based
    on global positioning systems or other cost-effective
    technology.
        (g) For the Home Services Program operated by the
    Department of Human Services and the Community Care
    Program operated by the Department on Aging, the
    Department of Human Services, in cooperation with the
    Department on Aging, shall implement an electronic service
    verification based on global positioning systems or other
    cost-effective technology.
        (h) Effective with inpatient hospital admissions on or
    after July 1, 2012, the Department shall reduce the
    payment for a claim that indicates the occurrence of a
    provider-preventable condition during the admission as
    specified by the Department in rules. The Department shall
    not pay for services related to an other
    provider-preventable condition.
        As used in this subsection (h):
        "Provider-preventable condition" means a health care
    acquired condition as defined under the federal Medicaid
    regulation found at 42 CFR 447.26 or an other
    provider-preventable condition.
        "Other provider-preventable condition" means a wrong
    surgical or other invasive procedure performed on a
    patient, a surgical or other invasive procedure performed
    on the wrong body part, or a surgical procedure or other
    invasive procedure performed on the wrong patient.
        (i) The Department shall implement cost savings
    initiatives for advanced imaging services, cardiac imaging
    services, pain management services, and back surgery. Such
    initiatives shall be designed to achieve annual costs
    savings.
        (j) The Department shall ensure that beneficiaries
    with a diagnosis of epilepsy or seizure disorder in
    Department records will not require prior approval for
    anticonvulsants.
(Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
 
Article 35.

 
    Section 35-5. The Illinois Public Aid Code is amended by
changing Section 5-5 and by adding Section 5-42 as follows:
 
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
    Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant women, provided by an individual licensed to
practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State. The term "any other type of remedial care"
shall include nursing care and nursing home service for
persons who rely on treatment by spiritual means alone through
prayer for healing.
    Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
    Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
    Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
    Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
    Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
    On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
        (1) dental services provided by or under the
    supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    the diseases of the eye, or by an optometrist, whichever
    the person may select.
    On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
    On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
    Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
    The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
    The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    age.
        (B) An annual mammogram for women 40 years of age or
    older.
        (C) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider
    for women under 40 years of age and having a family history
    of breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening and MRI of an
    entire breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue or when medically
    necessary as determined by a physician licensed to
    practice medicine in all of its branches.
        (E) A screening MRI when medically necessary, as
    determined by a physician licensed to practice medicine in
    all of its branches.
        (F) A diagnostic mammogram when medically necessary,
    as determined by a physician licensed to practice medicine
    in all its branches, advanced practice registered nurse,
    or physician assistant.
    The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
    All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
     For purposes of this Section:
    "Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
    "Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
    "Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
    "Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
    If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
    On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
    On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography.
    The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
    On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
    The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
    Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
    The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
    The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
    The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
    The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
    Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
    All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women in
addition to treatment for addiction.
    The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
    The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
    The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    providing certain services, which shall be determined by
    the Illinois Department, to persons in areas covered by
    the Partnership may receive an additional surcharge for
    such services.
        (2) The Department may elect to consider and negotiate
    financial incentives to encourage the development of
    Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    Partnerships may receive medical and case management
    services above the level usually offered through the
    medical assistance program.
    Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
    The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
    The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
    The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
    The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
    Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
    The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
    To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
        (1) In the case of a provider whose enrollment is in
    process by the Illinois Department, the 180-day period
    shall not begin until the date on the written notice from
    the Illinois Department that the provider enrollment is
    complete.
        (2) In the case of errors attributable to the Illinois
    Department or any of its claims processing intermediaries
    which result in an inability to receive, process, or
    adjudicate a claim, the 180-day period shall not begin
    until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    local government with a population exceeding 3,000,000
    when local government funds finance federal participation
    for claims payments.
    For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
    In the case of long term care facilities, within 45
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
    Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
    To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
    The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
    The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
    The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
    In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
    The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
    The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
    The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    Illinois Department.
    The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
    Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
    Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
    Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
    On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees related to the dispensing and administration of the
opioid antagonist, shall be covered under the medical
assistance program for persons who are otherwise eligible for
medical assistance under this Article. As used in this
Section, "opioid antagonist" means a drug that binds to opioid
receptors and blocks or inhibits the effect of opioids acting
on those receptors, including, but not limited to, naloxone
hydrochloride or any other similarly acting drug approved by
the U.S. Food and Drug Administration.
    Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
    A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
1-1-20; revised 9-18-19.)
 
    (305 ILCS 5/5-42 new)
    Sec. 5-42. Tobacco cessation coverage; managed care.
Notwithstanding any other provision of this Article, a managed
care organization under contract with the Department to
provide services to recipients of medical assistance shall
provide coverage for all tobacco cessation medications
approved by the United States Food and Drug Administration,
all individual and group tobacco cessation counseling
services, and all telephone-based counseling services and
tobacco cessation medications provided through the Illinois
Tobacco Quitline. The Department may adopt any rules necessary
to implement this Section.
 
Article 45.

 
    Section 45-5. The Illinois Public Aid Code is amended by
changing Section 12-4.35 as follows:
 
    (305 ILCS 5/12-4.35)
    Sec. 12-4.35. Medical services for certain noncitizens.
    (a) Notwithstanding Section 1-11 of this Code or Section
20(a) of the Children's Health Insurance Program Act, the
Department of Healthcare and Family Services may provide
medical services to noncitizens who have not yet attained 19
years of age and who are not eligible for medical assistance
under Article V of this Code or under the Children's Health
Insurance Program created by the Children's Health Insurance
Program Act due to their not meeting the otherwise applicable
provisions of Section 1-11 of this Code or Section 20(a) of the
Children's Health Insurance Program Act. The medical services
available, standards for eligibility, and other conditions of
participation under this Section shall be established by rule
by the Department; however, any such rule shall be at least as
restrictive as the rules for medical assistance under Article
V of this Code or the Children's Health Insurance Program
created by the Children's Health Insurance Program Act.
    (a-5) Notwithstanding Section 1-11 of this Code, the
Department of Healthcare and Family Services may provide
medical assistance in accordance with Article V of this Code
to noncitizens over the age of 65 years of age who are not
eligible for medical assistance under Article V of this Code
due to their not meeting the otherwise applicable provisions
of Section 1-11 of this Code, whose income is at or below 100%
of the federal poverty level after deducting the costs of
medical or other remedial care, and who would otherwise meet
the eligibility requirements in Section 5-2 of this Code. The
medical services available, standards for eligibility, and
other conditions of participation under this Section shall be
established by rule by the Department; however, any such rule
shall be at least as restrictive as the rules for medical
assistance under Article V of this Code.
    (a-10) Notwithstanding the provisions of Section 1-11, the
Department shall cover immunosuppressive drugs and related
services associated with post-kidney transplant management,
excluding long-term care costs, for noncitizens who: (i) are
not eligible for comprehensive medical benefits; (ii) meet the
residency requirements of Section 5-3; and (iii) would meet
the financial eligibility requirements of Section 5-2.
    (b) The Department is authorized to take any action,
including without limitation cessation or limitation of
enrollment, reduction of available medical services, and
changing standards for eligibility, that is deemed necessary
by the Department during a State fiscal year to assure that
payments under this Section do not exceed available funds.
    (c) Continued enrollment of individuals into the program
created under subsection (a) of this Section in any fiscal
year is contingent upon continued enrollment of individuals
into the Children's Health Insurance Program during that
fiscal year.
    (d) (Blank).
(Source: P.A. 101-636, eff. 6-10-20.)
 
Article 55.

 
    Section 55-5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
 
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
    Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant women, provided by an individual licensed to
practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State. The term "any other type of remedial care"
shall include nursing care and nursing home service for
persons who rely on treatment by spiritual means alone through
prayer for healing.
    Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
    Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
    Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
    Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
    On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
        (1) dental services provided by or under the
    supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    the diseases of the eye, or by an optometrist, whichever
    the person may select.
    On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
    On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
    Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
    The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
    The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    age.
        (B) An annual mammogram for women 40 years of age or
    older.
        (C) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider
    for women under 40 years of age and having a family history
    of breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening and MRI of an
    entire breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue or when medically
    necessary as determined by a physician licensed to
    practice medicine in all of its branches.
        (E) A screening MRI when medically necessary, as
    determined by a physician licensed to practice medicine in
    all of its branches.
        (F) A diagnostic mammogram when medically necessary,
    as determined by a physician licensed to practice medicine
    in all its branches, advanced practice registered nurse,
    or physician assistant.
    The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
    All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
     For purposes of this Section:
    "Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
    "Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
    "Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
    "Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
    If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
    On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
    On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography.
    The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
    On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
    The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
    Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
    The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
    The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
    The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
    The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
    Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
    All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women in
addition to treatment for addiction.
    The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
    The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
    The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    providing certain services, which shall be determined by
    the Illinois Department, to persons in areas covered by
    the Partnership may receive an additional surcharge for
    such services.
        (2) The Department may elect to consider and negotiate
    financial incentives to encourage the development of
    Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    Partnerships may receive medical and case management
    services above the level usually offered through the
    medical assistance program.
    Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
    The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
    Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
    The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
    The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
    The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
    Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
    The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
    To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
        (1) In the case of a provider whose enrollment is in
    process by the Illinois Department, the 180-day period
    shall not begin until the date on the written notice from
    the Illinois Department that the provider enrollment is
    complete.
        (2) In the case of errors attributable to the Illinois
    Department or any of its claims processing intermediaries
    which result in an inability to receive, process, or
    adjudicate a claim, the 180-day period shall not begin
    until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    local government with a population exceeding 3,000,000
    when local government funds finance federal participation
    for claims payments.
    For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
    In the case of long term care facilities, within 45
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
    Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
    To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
    The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
    The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
    The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
    In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
    The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
    The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
    The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    Illinois Department.
    The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
    Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
    Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
    Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
    On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees related to the dispensing and administration of the
opioid antagonist, shall be covered under the medical
assistance program for persons who are otherwise eligible for
medical assistance under this Article. As used in this
Section, "opioid antagonist" means a drug that binds to opioid
receptors and blocks or inhibits the effect of opioids acting
on those receptors, including, but not limited to, naloxone
hydrochloride or any other similarly acting drug approved by
the U.S. Food and Drug Administration.
    Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
    A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
    Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
1-1-20; revised 9-18-19.)
 
    Section 55-10. The All-Inclusive Care for the Elderly Act
is amended by changing Sections 1, 15 and 20 and by adding
Sections 6 and 16 as follows:
 
    (320 ILCS 40/1)  (from Ch. 23, par. 6901)
    Sec. 1. Short title. This Act may be cited as the Program
of All-Inclusive Care for the Elderly Act.
(Source: P.A. 87-411.)
 
    (320 ILCS 40/6 new)
    Sec. 6. Definitions. As used in this Act:
    "Department" means the Department of Healthcare and Family
Services.
    "PACE organization" means an entity as defined in 42 CFR
460.6.
 
    (320 ILCS 40/15)  (from Ch. 23, par. 6915)
    Sec. 15. Program implementation.
    (a) The Department of Healthcare and Family Services must
prepare and submit a PACE State Plan amendment no later than
December 31, 2022 to the federal Centers for Medicare and
Medicaid Services to establish the Program of All-Inclusive
Care for the Elderly (PACE program) to provide
community-based, risk-based, and capitated long-term care
services as optional services under the Illinois Title XIX
State Plan and under contracts entered into between the
federal Centers for Medicare and Medicaid Services, the
Department of Healthcare and Family Services, and PACE
organizations, meeting the requirements of the Balanced Budget
Act of 1997 (Public Law 105-33) and any other applicable law or
regulation. Upon receipt of federal approval, the Illinois
Department of Public Aid (now Department of Healthcare and
Family Services) shall implement the PACE program pursuant to
the provisions of the approved Title XIX State plan.
    (b) The Department of Healthcare and Family Services shall
facilitate the PACE organization application process no later
than December 31, 2023.
    (c) All PACE organizations selected shall begin operations
no later than June 30, 2024.
    (d) (b) Using a risk-based financing model, the
organizations contracted to implement nonprofit organization
providing the PACE program shall assume responsibility for all
costs generated by the PACE program participants, and it shall
create and maintain a risk reserve fund that will cover any
cost overages for any participant. The PACE program is
responsible for the entire range of services in the
consolidated service model, including hospital and nursing
home care, according to participant need as determined by a
multidisciplinary team. The contracted organizations are
nonprofit organization providing the PACE program is
responsible for the full financial risk. Specific arrangements
of the risk-based financing model shall be adopted and
negotiated by the federal Centers for Medicare and Medicaid
Services, the organizations contracted to implement nonprofit
organization providing the PACE program, and the Department of
Healthcare and Family Services.
    (e) The requirements of the PACE model, as provided for
under Section 1894 (42 U.S.C. Sec. 1395eee) and Section 1934
(42 U.S.C. Sec. 1396u-4) of the federal Social Security Act,
shall not be waived or modified. The requirements that shall
not be waived or modified include all of the following:
        (1) The focus on frail elderly qualifying individuals
    who require the level of care provided in a nursing
    facility.
        (2) The delivery of comprehensive, integrated acute
    and long-term care services.
        (3) The interdisciplinary team approach to care
    management and service delivery.
        (4) Capitated, integrated financing that allows the
    provider to pool payments received from public and private
    programs and individuals.
        (5) The assumption by the provider of full financial
    risk.
        (6) The provision of a PACE benefit package for all
    participants, regardless of source of payment, that shall
    include all of the following:
            (A) All Medicare-covered items and services.
            (B) All Medicaid-covered items and services, as
        specified in the Illinois Title XIX State Plan.
            (C) Other services determined necessary by the
        interdisciplinary team to improve and maintain the
        participant's overall health status.
    (f) The provisions under Sections 1-7 and 5-4 of the
Illinois Public Aid Code and under 80 Ill. Adm. Code 120.379,
120.380, and 120.385 shall apply when determining the
eligibility for medical assistance of a person receiving PACE
services from an organization providing services under this
Act.
    (g) Provisions governing the treatment of income and
resources of a married couple, for the purposes of determining
the eligibility of a nursing-facility certifiable or
institutionalized spouse, shall be established so as to
qualify for federal financial participation.
    (h) Notwithstanding subsection (e), and only to the extent
federal financial participation is available, the Department
of Healthcare and Family Services, in consultation with PACE
organizations, may seek increased federal regulatory
flexibility from the federal Centers for Medicare and Medicaid
Services to modernize the PACE program, which may include, but
is not limited to, addressing all of the following:
        (A) Composition of PACE interdisciplinary teams.
        (B) Use of community-based physicians.
        (C) Marketing practices.
        (D) Development of a streamlined PACE waiver process.
    This subsection shall be operative upon federal approval
of a capitation rate methodology as provided under Section 16.
    (i) Each PACE organization shall provide the Department
with required reporting documents as set forth in 42 CFR
460.190 through 42 CFR 460.196.
(Source: P.A. 94-48, eff. 7-1-05; 95-331, eff. 8-21-07.)
 
    (320 ILCS 40/16 new)
    Sec. 16. Rates of payment.
    (a) The General Assembly shall make appropriations to the
Department to fund services under this Act. The Department
shall develop and pay capitation rates to organizations
contracted to implement the PACE program as described in
Section 15 using actuarial methods.
    The Department may develop capitation rates using a
standardized rate methodology across managed care plan models
for comparable populations. The specific rate methodology
applied to PACE organizations shall address features of PACE
that distinguishes it from other managed care plan models.
    The rate methodology shall be consistent with actuarial
rate development principles and shall provide for all
reasonable, appropriate, and attainable costs for each PACE
organization within a region.
    (b) The Department may develop statewide rates and apply
geographic adjustments, using available data sources deemed
appropriate by the Department. Consistent with actuarial
methods, the primary source of data used to develop rates for
each PACE organization shall be its cost and utilization data
for the Medical Assistance Program or other data sources as
deemed necessary by the Department. Rates developed under this
Section shall reflect the level of care associated with the
specific populations served under the contract.
    (c) The rate methodology developed in accordance with this
Section shall contain a mechanism to account for the costs of
high-cost drugs and treatments. Rates developed shall be
actuarially certified prior to implementation.
    (d) Consistent with the requirements of federal law, the
Department shall calculate an upper payment limit for payments
to PACE organizations. In calculating the upper payment limit,
the Department shall collect the applicable data as necessary
and shall consider the risk of nursing home placement for the
comparable population when estimating the level of care and
risk of PACE participants.
    (e) The Department shall pay organizations contracted to
implement the PACE program at a rate within the certified
actuarially sound rate range developed with respect to that
entity as necessary to mitigate the impact to the entity of the
methodology developed in accordance with this Section.
    (f) This Section shall apply for rates established no
earlier than July 1, 2022.
 
    (320 ILCS 40/20)  (from Ch. 23, par. 6920)
    Sec. 20. Duties of the Department of Healthcare and Family
Services.
    (a) The Department of Healthcare and Family Services shall
provide a system for reimbursement for services to the PACE
program.
    (b) The Department of Healthcare and Family Services shall
develop and implement contracts a contract with organizations
as provided in subsection (d) of Section 15 that set the
nonprofit organization providing the PACE program that sets
forth contractual obligations for the PACE program, including,
but not limited to, reporting and monitoring of utilization of
costs of the program as required by the Illinois Department.
    (c) The Department of Healthcare and Family Services shall
acknowledge that it is participating in the national PACE
project as initiated by Congress.
    (d) The Department of Healthcare and Family Services or
its designee shall be responsible for certifying the
eligibility for services of all PACE program participants.
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (320 ILCS 40/30 rep.)
    Section 55-15. The All-Inclusive Care for the Elderly Act
is amended by repealing Section 30.
 
Article 65.

 
    Section 65-5. The Illinois Public Aid Code is amended by
changing Section 5-19 as follows:
 
    (305 ILCS 5/5-19)  (from Ch. 23, par. 5-19)
    Sec. 5-19. Healthy Kids Program.
    (a) Any child under the age of 21 eligible to receive
Medical Assistance from the Illinois Department under Article
V of this Code shall be eligible for Early and Periodic
Screening, Diagnosis and Treatment services provided by the
Healthy Kids Program of the Illinois Department under the
Social Security Act, 42 U.S.C. 1396d(r).
    (b) Enrollment of Children in Medicaid. The Illinois
Department shall provide for receipt and initial processing of
applications for Medical Assistance for all pregnant women and
children under the age of 21 at locations in addition to those
used for processing applications for cash assistance,
including disproportionate share hospitals, federally
qualified health centers and other sites as selected by the
Illinois Department.
    (c) Healthy Kids Examinations. The Illinois Department
shall consider any examination of a child eligible for the
Healthy Kids services provided by a medical provider meeting
the requirements and complying with the rules and regulations
of the Illinois Department to be reimbursed as a Healthy Kids
examination.
    (d) Medical Screening Examinations.
        (1) The Illinois Department shall insure Medicaid
    coverage for periodic health, vision, hearing, and dental
    screenings for children eligible for Healthy Kids services
    scheduled from a child's birth up until the child turns 21
    years. The Illinois Department shall pay for vision,
    hearing, dental and health screening examinations for any
    child eligible for Healthy Kids services by qualified
    providers at intervals established by Department rules.
        (2) The Illinois Department shall pay for an
    interperiodic health, vision, hearing, or dental screening
    examination for any child eligible for Healthy Kids
    services whenever an examination is:
            (A) requested by a child's parent, guardian, or
        custodian, or is determined to be necessary or
        appropriate by social services, developmental, health,
        or educational personnel; or
            (B) necessary for enrollment in school; or
            (C) necessary for enrollment in a licensed day
        care program, including Head Start; or
            (D) necessary for placement in a licensed child
        welfare facility, including a foster home, group home
        or child care institution; or
            (E) necessary for attendance at a camping program;
        or
            (F) necessary for participation in an organized
        athletic program; or
            (G) necessary for enrollment in an early childhood
        education program recognized by the Illinois State
        Board of Education; or
            (H) necessary for participation in a Women,
        Infant, and Children (WIC) program; or
            (I) deemed appropriate by the Illinois Department.
    (e) Minimum Screening Protocols For Periodic Health
Screening Examinations. Health Screening Examinations must
include the following services:
        (1) Comprehensive Health and Development Assessment
    including:
            (A) Development/Mental Health/Psychosocial
        Assessment; and
            (B) Assessment of nutritional status including
        tests for iron deficiency and anemia for children at
        the following ages: 9 months, 2 years, 8 years, and 18
        years;
        (2) Comprehensive unclothed physical exam;
        (3) Appropriate immunizations at a minimum, as
    required by the Secretary of the U.S. Department of Health
    and Human Services under 42 U.S.C. 1396d(r).
        (4) Appropriate laboratory tests including blood lead
    levels appropriate for age and risk factors.
            (A) Anemia test.
            (B) Sickle cell test.
            (C) Tuberculin test at 12 months of age and every
        1-2 years thereafter unless the treating health care
        professional determines that testing is medically
        contraindicated.
            (D) Other -- The Illinois Department shall insure
        that testing for HIV, drug exposure, and sexually
        transmitted diseases is provided for as clinically
        indicated.
        (5) Health Education. The Illinois Department shall
    require providers to provide anticipatory guidance as
    recommended by the American Academy of Pediatrics.
        (6) Vision Screening. The Illinois Department shall
    require providers to provide vision screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
        (7) Hearing Screening. The Illinois Department shall
    require providers to provide hearing screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
        (8) Dental Screening. The Illinois Department shall
    require providers to provide dental screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
    (f) Covered Medical Services. The Illinois Department
shall provide coverage for all necessary health care,
diagnostic services, treatment and other measures to correct
or ameliorate defects, physical and mental illnesses, and
conditions whether discovered by the screening services or not
for all children eligible for Medical Assistance under Article
V of this Code.
    (g) Notice of Healthy Kids Services.
        (1) The Illinois Department shall inform any child
    eligible for Healthy Kids services and the child's family
    about the benefits provided under the Healthy Kids
    Program, including, but not limited to, the following:
    what services are available under Healthy Kids, including
    discussion of the periodicity schedules and immunization
    schedules, that services are provided at no cost to
    eligible children, the benefits of preventive health care,
    where the services are available, how to obtain them, and
    that necessary transportation and scheduling assistance is
    available.
        (2) The Illinois Department shall widely disseminate
    information regarding the availability of the Healthy Kids
    Program throughout the State by outreach activities which
    shall include, but not be limited to, (i) the development
    of cooperation agreements with local school districts,
    public health agencies, clinics, hospitals and other
    health care providers, including developmental disability
    and mental health providers, and with charities, to notify
    the constituents of each of the Program and assist
    individuals, as feasible, with applying for the Program,
    (ii) using the media for public service announcements and
    advertisements of the Program, and (iii) developing
    posters advertising the Program for display in hospital
    and clinic waiting rooms.
        (3) The Illinois Department shall utilize accepted
    methods for informing persons who are illiterate, blind,
    deaf, or cannot understand the English language, including
    but not limited to public services announcements and
    advertisements in the foreign language media of radio,
    television and newspapers.
        (4) The Illinois Department shall provide notice of
    the Healthy Kids Program to every child eligible for
    Healthy Kids services and his or her family at the
    following times:
            (A) orally by the intake worker and in writing at
        the time of application for Medical Assistance;
            (B) at the time the applicant is informed that he
        or she is eligible for Medical Assistance benefits;
        and
            (C) at least 20 days before the date of any
        periodic health, vision, hearing, and dental
        examination for any child eligible for Healthy Kids
        services. Notice given under this subparagraph (C)
        must state that a screening examination is due under
        the periodicity schedules and must advise the eligible
        child and his or her family that the Illinois
        Department will provide assistance in scheduling an
        appointment and arranging medical transportation.
    (h) Data Collection. The Illinois Department shall collect
data in a usable form to track utilization of Healthy Kids
screening examinations by children eligible for Healthy Kids
services, including but not limited to data showing screening
examinations and immunizations received, a summary of
follow-up treatment received by children eligible for Healthy
Kids services and the number of children receiving dental,
hearing and vision services.
    (i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
    (j) To ensure full access to the benefits set forth in this
Section, on and after January 1, 2022, the Illinois Department
shall ensure that provider and hospital reimbursements for
immunization as required under this Section are no lower than
70% of the median regional maximum administration fee for the
State of Illinois as established by the U.S. Department of
Health and Human Services' Centers for Medicare and Medicaid
Services.
(Source: P.A. 97-689, eff. 6-14-12.)
 
Article 70.

 
    Section 70-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
 
    (305 ILCS 5/5-5.01a)
    Sec. 5-5.01a. Supportive living facilities program.
    (a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to
promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
    A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
    Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
    (b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.
    The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
    Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated.
    (c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
    (d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
        (1) those distinct parts of the site or building are
    not designated for the purpose of providing assisted
    living services as required under the Assisted Living and
    Shared Housing Act;
        (2) those distinct parts of the site or building are
    completely separate from the part of the building used for
    the provision of supportive living program services,
    including separate entrances;
        (3) those distinct parts of the site or building do
    not share any common spaces with the part of the building
    used for the provision of supportive living program
    services; and
        (4) those distinct parts of the site or building do
    not share staffing with the part of the building used for
    the provision of supportive living program services.
    (e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
    (f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to
receive the enhanced federal medical assistance percentage.
(Source: P.A. 100-23, eff. 7-6-17; 100-583, eff. 4-6-18;
100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)
 
Article 75.

 
    Section 75-5. The Illinois Health Information Exchange and
Technology Act is amended by adding Section 997 as follows:
 
    (20 ILCS 3860/997 new)
    Sec. 997. Repealer. This Act is repealed on January 1,
2027.
 
Article 80.

 
    Section 80-5. The Illinois Public Aid Code is amended by
changing Section 5-5f as follows:
 
    (305 ILCS 5/5-5f)
    Sec. 5-5f. Elimination and limitations of medical
assistance services. Notwithstanding any other provision of
this Code to the contrary, on and after July 1, 2012:
        (a) The following services shall no longer be a
    covered service available under this Code: group
    psychotherapy for residents of any facility licensed under
    the Nursing Home Care Act or the Specialized Mental Health
    Rehabilitation Act of 2013; and adult chiropractic
    services.
        (b) The Department shall place the following
    limitations on services: (i) the Department shall limit
    adult eyeglasses to one pair every 2 years; however, the
    limitation does not apply to an individual who needs
    different eyeglasses following a surgical procedure such
    as cataract surgery; (ii) the Department shall set an
    annual limit of a maximum of 20 visits for each of the
    following services: adult speech, hearing, and language
    therapy services, adult occupational therapy services, and
    physical therapy services; on or after October 1, 2014,
    the annual maximum limit of 20 visits shall expire but the
    Department may require prior approval for all individuals
    for speech, hearing, and language therapy services,
    occupational therapy services, and physical therapy
    services; (iii) the Department shall limit adult podiatry
    services to individuals with diabetes; on or after October
    1, 2014, podiatry services shall not be limited to
    individuals with diabetes; (iv) the Department shall pay
    for caesarean sections at the normal vaginal delivery rate
    unless a caesarean section was medically necessary; (v)
    the Department shall limit adult dental services to
    emergencies; beginning July 1, 2013, the Department shall
    ensure that the following conditions are recognized as
    emergencies: (A) dental services necessary for an
    individual in order for the individual to be cleared for a
    medical procedure, such as a transplant; (B) extractions
    and dentures necessary for a diabetic to receive proper
    nutrition; (C) extractions and dentures necessary as a
    result of cancer treatment; and (D) dental services
    necessary for the health of a pregnant woman prior to
    delivery of her baby; on or after July 1, 2014, adult
    dental services shall no longer be limited to emergencies,
    and dental services necessary for the health of a pregnant
    woman prior to delivery of her baby shall continue to be
    covered; and (vi) effective July 1, 2012, the Department
    shall place limitations and require concurrent review on
    every inpatient detoxification stay to prevent repeat
    admissions to any hospital for detoxification within 60
    days of a previous inpatient detoxification stay. The
    Department shall convene a workgroup of hospitals,
    substance abuse providers, care coordination entities,
    managed care plans, and other stakeholders to develop
    recommendations for quality standards, diversion to other
    settings, and admission criteria for patients who need
    inpatient detoxification, which shall be published on the
    Department's website no later than September 1, 2013.
        (c) The Department shall require prior approval of the
    following services: wheelchair repairs costing more than
    $750 $400, coronary artery bypass graft, and bariatric
    surgery consistent with Medicare standards concerning
    patient responsibility. Wheelchair repair prior approval
    requests shall be adjudicated within one business day of
    receipt of complete supporting documentation. Providers
    may not break wheelchair repairs into separate claims for
    purposes of staying under the $750 $400 threshold for
    requiring prior approval. The wholesale price of manual
    and power wheelchairs, durable medical equipment and
    supplies, and complex rehabilitation technology products
    and services shall be defined as actual acquisition cost
    including all discounts.
        (d) The Department shall establish benchmarks for
    hospitals to measure and align payments to reduce
    potentially preventable hospital readmissions, inpatient
    complications, and unnecessary emergency room visits. In
    doing so, the Department shall consider items, including,
    but not limited to, historic and current acuity of care
    and historic and current trends in readmission. The
    Department shall publish provider-specific historical
    readmission data and anticipated potentially preventable
    targets 60 days prior to the start of the program. In the
    instance of readmissions, the Department shall adopt
    policies and rates of reimbursement for services and other
    payments provided under this Code to ensure that, by June
    30, 2013, expenditures to hospitals are reduced by, at a
    minimum, $40,000,000.
        (e) The Department shall establish utilization
    controls for the hospice program such that it shall not
    pay for other care services when an individual is in
    hospice.
        (f) For home health services, the Department shall
    require Medicare certification of providers participating
    in the program and implement the Medicare face-to-face
    encounter rule. The Department shall require providers to
    implement auditable electronic service verification based
    on global positioning systems or other cost-effective
    technology.
        (g) For the Home Services Program operated by the
    Department of Human Services and the Community Care
    Program operated by the Department on Aging, the
    Department of Human Services, in cooperation with the
    Department on Aging, shall implement an electronic service
    verification based on global positioning systems or other
    cost-effective technology.
        (h) Effective with inpatient hospital admissions on or
    after July 1, 2012, the Department shall reduce the
    payment for a claim that indicates the occurrence of a
    provider-preventable condition during the admission as
    specified by the Department in rules. The Department shall
    not pay for services related to an other
    provider-preventable condition.
        As used in this subsection (h):
        "Provider-preventable condition" means a health care
    acquired condition as defined under the federal Medicaid
    regulation found at 42 CFR 447.26 or an other
    provider-preventable condition.
        "Other provider-preventable condition" means a wrong
    surgical or other invasive procedure performed on a
    patient, a surgical or other invasive procedure performed
    on the wrong body part, or a surgical procedure or other
    invasive procedure performed on the wrong patient.
        (i) The Department shall implement cost savings
    initiatives for advanced imaging services, cardiac imaging
    services, pain management services, and back surgery. Such
    initiatives shall be designed to achieve annual costs
    savings.
        (j) The Department shall ensure that beneficiaries
    with a diagnosis of epilepsy or seizure disorder in
    Department records will not require prior approval for
    anticonvulsants.
(Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)
 
Article 85.

 
    Section 85-5. The School Code is amended by changing
Section 14-15.01 as follows:
 
    (105 ILCS 5/14-15.01)  (from Ch. 122, par. 14-15.01)
    Sec. 14-15.01. Community and Residential Services
Authority.
    (a) (1) The Community and Residential Services Authority
is hereby created and shall consist of the following members:
    A representative of the State Board of Education;
    Four representatives of the Department of Human Services
appointed by the Secretary of Human Services, with one member
from the Division of Community Health and Prevention, one
member from the Division of Developmental Disabilities, one
member from the Division of Mental Health, and one member from
the Division of Rehabilitation Services;
    A representative of the Department of Children and Family
Services;
    A representative of the Department of Juvenile Justice;
    A representative of the Department of Healthcare and
Family Services;
    A representative of the Attorney General's Disability
Rights Advocacy Division;
    The Chairperson and Minority Spokesperson of the House and
Senate Committees on Elementary and Secondary Education or
their designees; and
    Six persons appointed by the Governor. Five of such
appointees shall be experienced or knowledgeable relative to
provision of services for individuals with a behavior disorder
or a severe emotional disturbance and shall include
representatives of both the private and public sectors, except
that no more than 2 of those 5 appointees may be from the
public sector and at least 2 must be or have been directly
involved in provision of services to such individuals. The
remaining member appointed by the Governor shall be or shall
have been a parent of an individual with a behavior disorder or
a severe emotional disturbance, and that appointee may be from
either the private or the public sector.
    (2) Members appointed by the Governor shall be appointed
for terms of 4 years and shall continue to serve until their
respective successors are appointed; provided that the terms
of the original appointees shall expire on August 1, 1990. Any
vacancy in the office of a member appointed by the Governor
shall be filled by appointment of the Governor for the
remainder of the term.
    A vacancy in the office of a member appointed by the
Governor exists when one or more of the following events
occur:
        (i) An appointee dies;
        (ii) An appointee files a written resignation with the
    Governor;
        (iii) An appointee ceases to be a legal resident of
    the State of Illinois; or
        (iv) An appointee fails to attend a majority of
    regularly scheduled Authority meetings in a fiscal year.
    Members who are representatives of an agency shall serve
at the will of the agency head. Membership on the Authority
shall cease immediately upon cessation of their affiliation
with the agency. If such a vacancy occurs, the appropriate
agency head shall appoint another person to represent the
agency.
    If a legislative member of the Authority ceases to be
Chairperson or Minority Spokesperson of the designated
Committees, they shall automatically be replaced on the
Authority by the person who assumes the position of
Chairperson or Minority Spokesperson.
    (b) The Community and Residential Services Authority shall
have the following powers and duties:
        (1) To conduct surveys to determine the extent of
    need, the degree to which documented need is currently
    being met and feasible alternatives for matching need with
    resources.
        (2) To develop policy statements for interagency
    cooperation to cover all aspects of service delivery,
    including laws, regulations and procedures, and clear
    guidelines for determining responsibility at all times.
        (3) To recommend policy statements and provide
    information regarding effective programs for delivery of
    services to all individuals under 22 years of age with a
    behavior disorder or a severe emotional disturbance in
    public or private situations.
        (4) To review the criteria for service eligibility,
    provision and availability established by the governmental
    agencies represented on this Authority, and to recommend
    changes, additions or deletions to such criteria.
        (5) To develop and submit to the Governor, the General
    Assembly, the Directors of the agencies represented on the
    Authority, and the State Board of Education a master plan
    for individuals under 22 years of age with a behavior
    disorder or a severe emotional disturbance, including
    detailed plans of service ranging from the least to the
    most restrictive options; and to assist local communities,
    upon request, in developing or strengthening collaborative
    interagency networks.
        (6) To develop a process for making determinations in
    situations where there is a dispute relative to a plan of
    service for individuals or funding for a plan of service.
        (7) To provide technical assistance to parents,
    service consumers, providers, and member agency personnel
    regarding statutory responsibilities of human service and
    educational agencies, and to provide such assistance as
    deemed necessary to appropriately access needed services.
        (8) To establish a pilot program to act as a
    residential research hub to research and identify
    appropriate residential settings for youth who are being
    housed in an emergency room for more than 72 hours or who
    are deemed beyond medical necessity in a psychiatric
    hospital. If a child is deemed beyond medical necessity in
    a psychiatric hospital and is in need of residential
    placement, the goal of the program is to prevent a
    lock-out pursuant to the goals of the Custody
    Relinquishment Prevention Act.
    (c) (1) The members of the Authority shall receive no
compensation for their services but shall be entitled to
reimbursement of reasonable expenses incurred while performing
their duties.
    (2) The Authority may appoint special study groups to
operate under the direction of the Authority and persons
appointed to such groups shall receive only reimbursement of
reasonable expenses incurred in the performance of their
duties.
    (3) The Authority shall elect from its membership a
chairperson, vice-chairperson and secretary.
    (4) The Authority may employ and fix the compensation of
such employees and technical assistants as it deems necessary
to carry out its powers and duties under this Act. Staff
assistance for the Authority shall be provided by the State
Board of Education.
    (5) Funds for the ordinary and contingent expenses of the
Authority shall be appropriated to the State Board of
Education in a separate line item.
    (d) (1) The Authority shall have power to promulgate rules
and regulations to carry out its powers and duties under this
Act.
    (2) The Authority may accept monetary gifts or grants from
the federal government or any agency thereof, from any
charitable foundation or professional association or from any
other reputable source for implementation of any program
necessary or desirable to the carrying out of the general
purposes of the Authority. Such gifts and grants may be held in
trust by the Authority and expended in the exercise of its
powers and performance of its duties as prescribed by law.
    (3) The Authority shall submit an annual report of its
activities and expenditures to the Governor, the General
Assembly, the directors of agencies represented on the
Authority, and the State Superintendent of Education.
    (e) The Executive Director of the Authority or his or her
designee shall be added as a participant on the Interagency
Clinical Team established in the intergovernmental agreement
among the Department of Healthcare and Family Services, the
Department of Children and Family Services, the Department of
Human Services, the State Board of Education, the Department
of Juvenile Justice, and the Department of Public Health, with
consent of the youth or the youth's guardian or family
pursuant to the Custody Relinquishment Prevention Act.
(Source: P.A. 95-331, eff. 8-21-07; 95-793, eff. 1-1-09.)
 
Article 90.

 
    Section 90-5. The Illinois Public Aid Code is amended by
adding Section 5-43 as follows:
 
    (305 ILCS 5/5-43 new)
    Sec. 5-43. Supports Waiver Program for Young Adults with
Developmental Disabilities.
    (a) The Department of Human Services' Division of
Developmental Disabilities, in partnership with the Department
of Healthcare and Family Services and stakeholders, shall
study the development and implementation of a supports waiver
program for young adults with developmental disabilities. The
Division shall explore the following components of a supports
waiver program to determine what is most appropriate:
        (1) The age of individuals to be provided services in
    a waiver program.
        (2) The number of individuals to be provided services
    in a waiver program.
        (3) The services to be provided in a waiver program.
        (4) The funding to be provided to individuals within a
    waiver program.
        (5) The transition process to the Waiver for Adults
    with Developmental Disabilities.
        (6) The type of home and community-based services
    waiver to be utilized.
    (b) The Department of Human Services and the Department of
Healthcare and Family Services are authorized to adopt and
implement any rules necessary to study the supports waiver
program.
    (c) Subject to appropriation, no later than January 1,
2024, the Department of Healthcare and Family Services shall
apply to the federal Centers for Medicare and Medicaid
Services for a supports waiver for young adults with
developmental disabilities utilizing the information learned
from the study under subsection (a).
 
Article 95.

 
    Section 95-5. The Illinois Public Aid Code is amended by
adding Section 5-5.06a as follows:
 
    (305 ILCS 5/5-5.06a new)
    Sec. 5-5.06a. Increased funding for dental services.
Beginning January 1, 2022, the amount allocated to fund rates
for dental services provided to adults and children under the
medical assistance program shall be increased by an
approximate amount of $10,000,000.
 
Article 105.

 
    Section 105-5. The Illinois Public Aid Code is amended by
changing Section 5-30.1 as follows:
 
    (305 ILCS 5/5-30.1)
    Sec. 5-30.1. Managed care protections.
    (a) As used in this Section:
    "Managed care organization" or "MCO" means any entity
which contracts with the Department to provide services where
payment for medical services is made on a capitated basis.
    "Emergency services" include:
        (1) emergency services, as defined by Section 10 of
    the Managed Care Reform and Patient Rights Act;
        (2) emergency medical screening examinations, as
    defined by Section 10 of the Managed Care Reform and
    Patient Rights Act;
        (3) post-stabilization medical services, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    Act; and
        (4) emergency medical conditions, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    Act.
    (b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed
Care Reform and Patient Rights Act.
    (c) An MCO shall pay any provider of emergency services
that does not have in effect a contract with the contracted
Medicaid MCO. The default rate of reimbursement shall be the
rate paid under Illinois Medicaid fee-for-service program
methodology, including all policy adjusters, including but not
limited to Medicaid High Volume Adjustments, Medicaid
Percentage Adjustments, Outpatient High Volume Adjustments,
and all outlier add-on adjustments to the extent such
adjustments are incorporated in the development of the
applicable MCO capitated rates.
    (d) An MCO shall pay for all post-stabilization services
as a covered service in any of the following situations:
        (1) the MCO authorized such services;
        (2) such services were administered to maintain the
    enrollee's stabilized condition within one hour after a
    request to the MCO for authorization of further
    post-stabilization services;
        (3) the MCO did not respond to a request to authorize
    such services within one hour;
        (4) the MCO could not be contacted; or
        (5) the MCO and the treating provider, if the treating
    provider is a non-affiliated provider, could not reach an
    agreement concerning the enrollee's care and an affiliated
    provider was unavailable for a consultation, in which case
    the MCO must pay for such services rendered by the
    treating non-affiliated provider until an affiliated
    provider was reached and either concurred with the
    treating non-affiliated provider's plan of care or assumed
    responsibility for the enrollee's care. Such payment shall
    be made at the default rate of reimbursement paid under
    Illinois Medicaid fee-for-service program methodology,
    including all policy adjusters, including but not limited
    to Medicaid High Volume Adjustments, Medicaid Percentage
    Adjustments, Outpatient High Volume Adjustments and all
    outlier add-on adjustments to the extent that such
    adjustments are incorporated in the development of the
    applicable MCO capitated rates.
    (e) The following requirements apply to MCOs in
determining payment for all emergency services:
        (1) MCOs shall not impose any requirements for prior
    approval of emergency services.
        (2) The MCO shall cover emergency services provided to
    enrollees who are temporarily away from their residence
    and outside the contracting area to the extent that the
    enrollees would be entitled to the emergency services if
    they still were within the contracting area.
        (3) The MCO shall have no obligation to cover medical
    services provided on an emergency basis that are not
    covered services under the contract.
        (4) The MCO shall not condition coverage for emergency
    services on the treating provider notifying the MCO of the
    enrollee's screening and treatment within 10 days after
    presentation for emergency services.
        (5) The determination of the attending emergency
    physician, or the provider actually treating the enrollee,
    of whether an enrollee is sufficiently stabilized for
    discharge or transfer to another facility, shall be
    binding on the MCO. The MCO shall cover emergency services
    for all enrollees whether the emergency services are
    provided by an affiliated or non-affiliated provider.
        (6) The MCO's financial responsibility for
    post-stabilization care services it has not pre-approved
    ends when:
            (A) a plan physician with privileges at the
        treating hospital assumes responsibility for the
        enrollee's care;
            (B) a plan physician assumes responsibility for
        the enrollee's care through transfer;
            (C) a contracting entity representative and the
        treating physician reach an agreement concerning the
        enrollee's care; or
            (D) the enrollee is discharged.
    (f) Network adequacy and transparency.
        (1) The Department shall:
            (A) ensure that an adequate provider network is in
        place, taking into consideration health professional
        shortage areas and medically underserved areas;
            (B) publicly release an explanation of its process
        for analyzing network adequacy;
            (C) periodically ensure that an MCO continues to
        have an adequate network in place;
            (D) require MCOs, including Medicaid Managed Care
        Entities as defined in Section 5-30.2, to meet
        provider directory requirements under Section 5-30.3;
        and
            (E) require MCOs to ensure that any
        Medicaid-certified provider under contract with an MCO
        and previously submitted on a roster on the date of
        service is paid for any medically necessary,
        Medicaid-covered, and authorized service rendered to
        any of the MCO's enrollees, regardless of inclusion on
        the MCO's published and publicly available directory
        of available providers.
        (2) Each MCO shall confirm its receipt of information
    submitted specific to physician or dentist additions or
    physician or dentist deletions from the MCO's provider
    network within 3 days after receiving all required
    information from contracted physicians or dentists, and
    electronic physician and dental directories must be
    updated consistent with current rules as published by the
    Centers for Medicare and Medicaid Services or its
    successor agency.
    (g) Timely payment of claims.
        (1) The MCO shall pay a claim within 30 days of
    receiving a claim that contains all the essential
    information needed to adjudicate the claim.
        (2) The MCO shall notify the billing party of its
    inability to adjudicate a claim within 30 days of
    receiving that claim.
        (3) The MCO shall pay a penalty that is at least equal
    to the timely payment interest penalty imposed under
    Section 368a of the Illinois Insurance Code for any claims
    not timely paid.
            (A) When an MCO is required to pay a timely payment
        interest penalty to a provider, the MCO must calculate
        and pay the timely payment interest penalty that is
        due to the provider within 30 days after the payment of
        the claim. In no event shall a provider be required to
        request or apply for payment of any owed timely
        payment interest penalties.
            (B) Such payments shall be reported separately
        from the claim payment for services rendered to the
        MCO's enrollee and clearly identified as interest
        payments.
        (4)(A) The Department shall require MCOs to expedite
    payments to providers identified on the Department's
    expedited provider list, determined in accordance with 89
    Ill. Adm. Code 140.71(b), on a schedule at least as
    frequently as the providers are paid under the
    Department's fee-for-service expedited provider schedule.
        (B) Compliance with the expedited provider requirement
    may be satisfied by an MCO through the use of a Periodic
    Interim Payment (PIP) program that has been mutually
    agreed to and documented between the MCO and the provider,
    if the PIP program ensures that any expedited provider
    receives regular and periodic payments based on prior
    period payment experience from that MCO. Total payments
    under the PIP program may be reconciled against future PIP
    payments on a schedule mutually agreed to between the MCO
    and the provider.
        (C) The Department shall share at least monthly its
    expedited provider list and the frequency with which it
    pays providers on the expedited list.
    (g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
        (1) in no instance shall a medically necessary covered
    service rendered in good faith, based upon eligibility
    information documented by the provider, be denied coverage
    or diminished in payment amount if the eligibility or
    coverage information available at the time the service was
    rendered is later found to be inaccurate in the assignment
    of coverage responsibility between MCOs or the
    fee-for-service system, except for instances when an
    individual is deemed to have not been eligible for
    coverage under the Illinois Medicaid program; and
        (2) the Department shall, by December 31, 2016, adopt
    rules establishing policies that shall be included in the
    Medicaid managed care policy and procedures manual
    addressing payment resolutions in situations in which a
    provider renders services based upon information obtained
    after verifying a patient's eligibility and coverage plan
    through either the Department's current enrollment system
    or a system operated by the coverage plan identified by
    the patient presenting for services:
            (A) such medically necessary covered services
        shall be considered rendered in good faith;
            (B) such policies and procedures shall be
        developed in consultation with industry
        representatives of the Medicaid managed care health
        plans and representatives of provider associations
        representing the majority of providers within the
        identified provider industry; and
            (C) such rules shall be published for a review and
        comment period of no less than 30 days on the
        Department's website with final rules remaining
        available on the Department's website.
        The rules on payment resolutions shall include, but
    not be limited to:
            (A) the extension of the timely filing period;
            (B) retroactive prior authorizations; and
            (C) guaranteed minimum payment rate of no less
        than the current, as of the date of service,
        fee-for-service rate, plus all applicable add-ons,
        when the resulting service relationship is out of
        network.
        The rules shall be applicable for both MCO coverage
    and fee-for-service coverage.
    If the fee-for-service system is ultimately determined to
have been responsible for coverage on the date of service, the
Department shall provide for an extended period for claims
submission outside the standard timely filing requirements.
    (g-6) MCO Performance Metrics Report.
        (1) The Department shall publish, on at least a
    quarterly basis, each MCO's operational performance,
    including, but not limited to, the following categories of
    metrics:
            (A) claims payment, including timeliness and
        accuracy;
            (B) prior authorizations;
            (C) grievance and appeals;
            (D) utilization statistics;
            (E) provider disputes;
            (F) provider credentialing; and
            (G) member and provider customer service.
        (2) The Department shall ensure that the metrics
    report is accessible to providers online by January 1,
    2017.
        (3) The metrics shall be developed in consultation
    with industry representatives of the Medicaid managed care
    health plans and representatives of associations
    representing the majority of providers within the
    identified industry.
        (4) Metrics shall be defined and incorporated into the
    applicable Managed Care Policy Manual issued by the
    Department.
    (g-7) MCO claims processing and performance analysis. In
order to monitor MCO payments to hospital providers, pursuant
to this amendatory Act of the 100th General Assembly, the
Department shall post an analysis of MCO claims processing and
payment performance on its website every 6 months. Such
analysis shall include a review and evaluation of a
representative sample of hospital claims that are rejected and
denied for clean and unclean claims and the top 5 reasons for
such actions and timeliness of claims adjudication, which
identifies the percentage of claims adjudicated within 30, 60,
90, and over 90 days, and the dollar amounts associated with
those claims. The Department shall post the contracted claims
report required by HealthChoice Illinois on its website every
3 months.
    (g-8) Dispute resolution process. The Department shall
maintain a provider complaint portal through which a provider
can submit to the Department unresolved disputes with an MCO.
An unresolved dispute means an MCO's decision that denies in
whole or in part a claim for reimbursement to a provider for
health care services rendered by the provider to an enrollee
of the MCO with which the provider disagrees. Disputes shall
not be submitted to the portal until the provider has availed
itself of the MCO's internal dispute resolution process.
Disputes that are submitted to the MCO internal dispute
resolution process may be submitted to the Department of
Healthcare and Family Services' complaint portal no sooner
than 30 days after submitting to the MCO's internal process
and not later than 30 days after the unsatisfactory resolution
of the internal MCO process or 60 days after submitting the
dispute to the MCO internal process. Multiple claim disputes
involving the same MCO may be submitted in one complaint,
regardless of whether the claims are for different enrollees,
when the specific reason for non-payment of the claims
involves a common question of fact or policy. Within 10
business days of receipt of a complaint, the Department shall
present such disputes to the appropriate MCO, which shall then
have 30 days to issue its written proposal to resolve the
dispute. The Department may grant one 30-day extension of this
time frame to one of the parties to resolve the dispute. If the
dispute remains unresolved at the end of this time frame or the
provider is not satisfied with the MCO's written proposal to
resolve the dispute, the provider may, within 30 days, request
the Department to review the dispute and make a final
determination. Within 30 days of the request for Department
review of the dispute, both the provider and the MCO shall
present all relevant information to the Department for
resolution and make individuals with knowledge of the issues
available to the Department for further inquiry if needed.
Within 30 days of receiving the relevant information on the
dispute, or the lapse of the period for submitting such
information, the Department shall issue a written decision on
the dispute based on contractual terms between the provider
and the MCO, contractual terms between the MCO and the
Department of Healthcare and Family Services and applicable
Medicaid policy. The decision of the Department shall be
final. By January 1, 2020, the Department shall establish by
rule further details of this dispute resolution process.
Disputes between MCOs and providers presented to the
Department for resolution are not contested cases, as defined
in Section 1-30 of the Illinois Administrative Procedure Act,
conferring any right to an administrative hearing.
    (g-9)(1) The Department shall publish annually on its
website a report on the calculation of each managed care
organization's medical loss ratio showing the following:
        (A) Premium revenue, with appropriate adjustments.
        (B) Benefit expense, setting forth the aggregate
    amount spent for the following:
            (i) Direct paid claims.
            (ii) Subcapitation payments.
            (iii) Other claim payments.
            (iv) Direct reserves.
            (v) Gross recoveries.
            (vi) Expenses for activities that improve health
        care quality as allowed by the Department.
    (2) The medical loss ratio shall be calculated consistent
with federal law and regulation following a claims runout
period determined by the Department.
    (g-10)(1) "Liability effective date" means the date on
which an MCO becomes responsible for payment for medically
necessary and covered services rendered by a provider to one
of its enrollees in accordance with the contract terms between
the MCO and the provider. The liability effective date shall
be the later of:
        (A) The execution date of a network participation
    contract agreement.
        (B) The date the provider or its representative
    submits to the MCO the complete and accurate standardized
    roster form for the provider in the format approved by the
    Department.
        (C) The provider effective date contained within the
    Department's provider enrollment subsystem within the
    Illinois Medicaid Program Advanced Cloud Technology
    (IMPACT) System.
    (2) The standardized roster form may be submitted to the
MCO at the same time that the provider submits an enrollment
application to the Department through IMPACT.
    (3) By October 1, 2019, the Department shall require all
MCOs to update their provider directory with information for
new practitioners of existing contracted providers within 30
days of receipt of a complete and accurate standardized roster
template in the format approved by the Department provided
that the provider is effective in the Department's provider
enrollment subsystem within the IMPACT system. Such provider
directory shall be readily accessible for purposes of
selecting an approved health care provider and comply with all
other federal and State requirements.
    (g-11) The Department shall work with relevant
stakeholders on the development of operational guidelines to
enhance and improve operational performance of Illinois'
Medicaid managed care program, including, but not limited to,
improving provider billing practices, reducing claim
rejections and inappropriate payment denials, and
standardizing processes, procedures, definitions, and response
timelines, with the goal of reducing provider and MCO
administrative burdens and conflict. The Department shall
include a report on the progress of these program improvements
and other topics in its Fiscal Year 2020 annual report to the
General Assembly.
    (g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for
payment in a non-electronic format, a provider shall always be
afforded a period of no less than 90 business days, as a
correction period, following any notification of rejection by
either the Department or the MCO to correct errors or
omissions in the original submission.
    Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
    (h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not
the seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.
    (i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after June 16, 2014 (the effective date of Public
Act 98-651).
    (j) Health care information released to managed care
organizations. A health care provider shall release to a
Medicaid managed care organization, upon request, and subject
to the Health Insurance Portability and Accountability Act of
1996 and any other law applicable to the release of health
information, the health care information of the MCO's
enrollee, if the enrollee has completed and signed a general
release form that grants to the health care provider
permission to release the recipient's health care information
to the recipient's insurance carrier.
    (k) The Department of Healthcare and Family Services,
managed care organizations, a statewide organization
representing hospitals, and a statewide organization
representing safety-net hospitals shall explore ways to
support billing departments in safety-net hospitals.
    (l) The requirements of this Section added by this
amendatory Act of the 102nd General Assembly shall apply to
services provided on or after the first day of the month that
begins 60 days after the effective date of this amendatory Act
of the 102nd General Assembly.
(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
 
Article 999.

 
    Section 999-99. Effective date. This Act takes effect upon
becoming law.