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Public Act 103-0808 | ||||
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AN ACT concerning regulation. | ||||
Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly: | ||||
Section 5. The Counties Code is amended by changing | ||||
Section 5-1069 as follows: | ||||
(55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069) | ||||
Sec. 5-1069. Group life, health, accident, hospital, and | ||||
medical insurance. | ||||
(a) The county board of any county may arrange to provide, | ||||
for the benefit of employees of the county, group life, | ||||
health, accident, hospital, and medical insurance, or any one | ||||
or any combination of those types of insurance, or the county | ||||
board may self-insure, for the benefit of its employees, all | ||||
or a portion of the employees' group life, health, accident, | ||||
hospital, and medical insurance, or any one or any combination | ||||
of those types of insurance, including a combination of | ||||
self-insurance and other types of insurance authorized by this | ||||
Section, provided that the county board complies with all | ||||
other requirements of this Section. The insurance may include | ||||
provision for employees who rely on treatment by prayer or | ||||
spiritual means alone for healing in accordance with the | ||||
tenets and practice of a well recognized religious | ||||
denomination. The county board may provide for payment by the |
county of a portion or all of the premium or charge for the | ||
insurance with the employee paying the balance of the premium | ||
or charge, if any. If the county board undertakes a plan under | ||
which the county pays only a portion of the premium or charge, | ||
the county board shall provide for withholding and deducting | ||
from the compensation of those employees who consent to join | ||
the plan the balance of the premium or charge for the | ||
insurance. | ||
(b) If the county board does not provide for | ||
self-insurance or for a plan under which the county pays a | ||
portion or all of the premium or charge for a group insurance | ||
plan, the county board may provide for withholding and | ||
deducting from the compensation of those employees who consent | ||
thereto the total premium or charge for any group life, | ||
health, accident, hospital, and medical insurance. | ||
(c) The county board may exercise the powers granted in | ||
this Section only if it provides for self-insurance or, where | ||
it makes arrangements to provide group insurance through an | ||
insurance carrier, if the kinds of group insurance are | ||
obtained from an insurance company authorized to do business | ||
in the State of Illinois. The county board may enact an | ||
ordinance prescribing the method of operation of the insurance | ||
program. | ||
(d) If a county, including a home rule county, is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, the insurance coverage shall |
include screening by low-dose mammography for all patients | ||
women 35 years of age or older for the presence of occult | ||
breast cancer unless the county elects to provide mammograms | ||
itself under Section 5-1069.1. The coverage shall be as | ||
follows: | ||
(1) A baseline mammogram for patients women 35 to 39 | ||
years of age. | ||
(2) An annual mammogram for patients women 40 years of | ||
age or older. | ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the patient's woman's health care | ||
provider for patients 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. | ||
(4) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after January 1, 2020 ( the effective date of Public | ||
Act 101-580) this amendatory Act of the 101st General | ||
Assembly , a comprehensive ultrasound screening 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, advanced | ||
practice registered nurse, or physician assistant. | ||
(4.5) For a group policy of accident and health |
insurance that is amended, delivered, issued, or renewed | ||
on or after the effective date of this amendatory Act of | ||
the 103rd General Assembly, molecular breast imaging (MBI) | ||
and magnetic resonance imaging 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, advanced practice registered nurse, or physician | ||
assistant. | ||
(5) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after January 1, 2020 ( the effective date of Public | ||
Act 101-580) this amendatory Act of the 101st General | ||
Assembly , 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. | ||
A policy subject to this subsection shall not impose a | ||
deductible, coinsurance, copayment, or any other cost-sharing | ||
requirement on the coverage provided; 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). | ||
For purposes of this subsection: |
"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. | ||
(d-5) Coverage as described by subsection (d) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(d-10) When health care services are available through | ||
contracted providers and a person does not comply with plan | ||
provisions specific to the use of contracted providers, the | ||
requirements of subsection (d-5) are not applicable. When a | ||
person does not comply with plan provisions specific to the | ||
use of contracted providers, plan provisions specific to the | ||
use of non-contracted providers must be applied without | ||
distinction for coverage required by this Section and shall be | ||
at least as favorable as for other radiological examinations | ||
covered by the policy or contract. |
(d-15) If a county, including a home rule county, is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, the insurance coverage shall | ||
include mastectomy coverage, which includes coverage for | ||
prosthetic devices or reconstructive surgery incident to the | ||
mastectomy. Coverage for breast reconstruction in connection | ||
with a mastectomy shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the | ||
mastectomy, and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no | ||
evidence of malignancy then the offered coverage may be | ||
limited to the provision of prosthetic devices and | ||
reconstructive surgery to within 2 years after the date of the | ||
mastectomy. As used in this Section, "mastectomy" means the | ||
removal of all or part of the breast for medically necessary | ||
reasons, as determined by a licensed physician. |
A county, including a home rule county, that is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, may not penalize or reduce or | ||
limit the reimbursement of an attending provider or provide | ||
incentives (monetary or otherwise) to an attending provider to | ||
induce the provider to provide care to an insured in a manner | ||
inconsistent with this Section. | ||
(d-20) The requirement that mammograms be included in | ||
health insurance coverage as provided in subsections (d) | ||
through (d-15) is an exclusive power and function of the State | ||
and is a denial and limitation under Article VII, Section 6, | ||
subsection (h) of the Illinois Constitution of home rule | ||
county powers. A home rule county to which subsections (d) | ||
through (d-15) apply must comply with every provision of those | ||
subsections. | ||
(e) The term "employees" as used in this Section includes | ||
elected or appointed officials but does not include temporary | ||
employees. | ||
(f) The county board may, by ordinance, arrange to provide | ||
group life, health, accident, hospital, and medical insurance, | ||
or any one or a combination of those types of insurance, under | ||
this Section to retired former employees and retired former | ||
elected or appointed officials of the county. | ||
(g) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, 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. | ||
(Source: P.A. 100-513, eff. 1-1-18; 101-580, eff. 1-1-20 .) | ||
Section 10. The Illinois Municipal Code is amended by | ||
changing Section 10-4-2 as follows: | ||
(65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2) | ||
Sec. 10-4-2. Group insurance. | ||
(a) The corporate authorities of any municipality may | ||
arrange to provide, for the benefit of employees of the | ||
municipality, group life, health, accident, hospital, and | ||
medical insurance, or any one or any combination of those | ||
types of insurance, and may arrange to provide that insurance | ||
for the benefit of the spouses or dependents of those | ||
employees. The insurance may include provision for employees | ||
or other insured persons who rely on treatment by prayer or | ||
spiritual means alone for healing in accordance with the | ||
tenets and practice of a well recognized religious | ||
denomination. The corporate authorities may provide for | ||
payment by the municipality of a portion of the premium or | ||
charge for the insurance with the employee paying the balance | ||
of the premium or charge. If the corporate authorities | ||
undertake a plan under which the municipality pays a portion |
of the premium or charge, the corporate authorities shall | ||
provide for withholding and deducting from the compensation of | ||
those municipal employees who consent to join the plan the | ||
balance of the premium or charge for the insurance. | ||
(b) If the corporate authorities do not provide for a plan | ||
under which the municipality pays a portion of the premium or | ||
charge for a group insurance plan, the corporate authorities | ||
may provide for withholding and deducting from the | ||
compensation of those employees who consent thereto the | ||
premium or charge for any group life, health, accident, | ||
hospital, and medical insurance. | ||
(c) The corporate authorities may exercise the powers | ||
granted in this Section only if the kinds of group insurance | ||
are obtained from an insurance company authorized to do | ||
business in the State of Illinois, or are obtained through an | ||
intergovernmental joint self-insurance pool as authorized | ||
under the Intergovernmental Cooperation Act. The corporate | ||
authorities may enact an ordinance prescribing the method of | ||
operation of the insurance program. | ||
(d) If a municipality, including a home rule municipality, | ||
is a self-insurer for purposes of providing health insurance | ||
coverage for its employees, the insurance coverage shall | ||
include screening by low-dose mammography for all patients | ||
women 35 years of age or older for the presence of occult | ||
breast cancer unless the municipality elects to provide | ||
mammograms itself under Section 10-4-2.1. The coverage shall |
be as follows: | ||
(1) A baseline mammogram for patients women 35 to 39 | ||
years of age. | ||
(2) An annual mammogram for patients women 40 years of | ||
age or older. | ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the patient's woman's health care | ||
provider for patients 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. | ||
(4) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after January 1, 2020 ( the effective date of Public | ||
Act 101-580) this amendatory Act of the 101st General | ||
Assembly , a comprehensive ultrasound screening 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. | ||
(4.5) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after the effective date of this amendatory Act of | ||
the 103rd General Assembly, molecular breast imaging (MBI) | ||
and magnetic resonance imaging 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, advanced practice registered nurse, or physician | ||
assistant. | ||
(5) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after January 1, 2020, ( the effective date of Public | ||
Act 101-580) this amendatory Act of the 101st General | ||
Assembly , 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. | ||
A policy subject to this subsection shall not impose a | ||
deductible, coinsurance, copayment, or any other cost-sharing | ||
requirement on the coverage provided; 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). | ||
For purposes of this subsection: | ||
"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. | ||
(d-5) Coverage as described by subsection (d) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(d-10) When health care services are available through | ||
contracted providers and a person does not comply with plan | ||
provisions specific to the use of contracted providers, the | ||
requirements of subsection (d-5) are not applicable. When a | ||
person does not comply with plan provisions specific to the | ||
use of contracted providers, plan provisions specific to the | ||
use of non-contracted providers must be applied without | ||
distinction for coverage required by this Section and shall be | ||
at least as favorable as for other radiological examinations | ||
covered by the policy or contract. | ||
(d-15) If a municipality, including a home rule | ||
municipality, is a self-insurer for purposes of providing | ||
health insurance coverage for its employees, the insurance | ||
coverage shall include mastectomy coverage, which includes | ||
coverage for prosthetic devices or reconstructive surgery |
incident to the mastectomy. Coverage for breast reconstruction | ||
in connection with a mastectomy shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the | ||
mastectomy, and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no | ||
evidence of malignancy then the offered coverage may be | ||
limited to the provision of prosthetic devices and | ||
reconstructive surgery to within 2 years after the date of the | ||
mastectomy. As used in this Section, "mastectomy" means the | ||
removal of all or part of the breast for medically necessary | ||
reasons, as determined by a licensed physician. | ||
A municipality, including a home rule municipality, that | ||
is a self-insurer for purposes of providing health insurance | ||
coverage for its employees, may not penalize or reduce or | ||
limit the reimbursement of an attending provider or provide | ||
incentives (monetary or otherwise) to an attending provider to |
induce the provider to provide care to an insured in a manner | ||
inconsistent with this Section. | ||
(d-20) The requirement that mammograms be included in | ||
health insurance coverage as provided in subsections (d) | ||
through (d-15) is an exclusive power and function of the State | ||
and is a denial and limitation under Article VII, Section 6, | ||
subsection (h) of the Illinois Constitution of home rule | ||
municipality powers. A home rule municipality to which | ||
subsections (d) through (d-15) apply must comply with every | ||
provision of those subsections. | ||
(e) 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. | ||
(Source: P.A. 100-863, eff. 8-14-18; 101-580, eff. 1-1-20 .) | ||
Section 15. The Illinois Insurance Code is amended by | ||
changing Section 356g as follows: | ||
(215 ILCS 5/356g) (from Ch. 73, par. 968g) | ||
Sec. 356g. Mammograms; mastectomies. | ||
(a) Every insurer shall provide in each group or | ||
individual policy, contract, or certificate of insurance | ||
issued or renewed for persons who are residents of this State, |
coverage for screening by low-dose mammography for all | ||
patients women 35 years of age or older for the presence of | ||
occult breast cancer within the provisions of the policy, | ||
contract, or certificate. The coverage shall be as follows: | ||
(1) A baseline mammogram for patients women 35 to 39 | ||
years of age. | ||
(2) An annual mammogram for patients women 40 years | ||
of age or older. | ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the patient's woman's health care | ||
provider for patients 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. | ||
(4) For an individual or group policy of accident and | ||
health insurance or a managed care plan that is amended, | ||
delivered, issued, or renewed on or after January 1, 2020 | ||
( the effective date of Public Act 101-580) and before the | ||
effective date of this amendatory Act of the 103rd General | ||
Assembly this amendatory Act of the 101st General | ||
Assembly , 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. | ||
(4.3) For an individual or group policy of accident |
and health insurance or a managed care plan that is | ||
amended, delivered, issued, or renewed on or after the | ||
effective date of this amendatory Act of the 103rd General | ||
Assembly, 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, advanced | ||
practice registered nurse, or physician assistant. | ||
(4.5) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after the effective date of this amendatory Act of | ||
the 103rd General Assembly, molecular breast imaging (MBI) | ||
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, advanced | ||
practice registered nurse, or physician assistant. | ||
(5) A screening MRI when medically necessary, as | ||
determined by a physician licensed to practice medicine in | ||
all of its branches. | ||
(6) For an individual or group policy of accident and | ||
health insurance or a managed care plan that is amended, | ||
delivered, issued, or renewed on or after January 1, 2020 | ||
( the effective date of Public Act 101-580) this amendatory | ||
Act of the 101st General Assembly , 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. | ||
A policy subject to this subsection shall not impose a | ||
deductible, coinsurance, copayment, or any other cost-sharing | ||
requirement on the coverage provided; 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). | ||
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 radiation exposure delivery of less than | ||
1 rad per breast for 2 views of an average size breast. The | ||
term also includes digital mammography and includes breast |
tomosynthesis. As used in this Section, the term "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 | ||
subsection, 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 subsection. | ||
(a-5) Coverage as described by subsection (a) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(a-10) When health care services are available through | ||
contracted providers and a person does not comply with plan |
provisions specific to the use of contracted providers, the | ||
requirements of subsection (a-5) are not applicable. When a | ||
person does not comply with plan provisions specific to the | ||
use of contracted providers, plan provisions specific to the | ||
use of non-contracted providers must be applied without | ||
distinction for coverage required by this Section and shall be | ||
at least as favorable as for other radiological examinations | ||
covered by the policy or contract. | ||
(b) No policy of accident or health insurance that | ||
provides for the surgical procedure known as a mastectomy | ||
shall be issued, amended, delivered, or renewed in this State | ||
unless that coverage also provides for prosthetic devices or | ||
reconstructive surgery incident to the mastectomy. Coverage | ||
for breast reconstruction in connection with a mastectomy | ||
shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the |
mastectomy, and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no | ||
evidence of malignancy then the offered coverage may be | ||
limited to the provision of prosthetic devices and | ||
reconstructive surgery to within 2 years after the date of the | ||
mastectomy. As used in this Section, "mastectomy" means the | ||
removal of all or part of the breast for medically necessary | ||
reasons, as determined by a licensed physician. | ||
Written notice of the availability of coverage under this | ||
Section shall be delivered to the insured upon enrollment and | ||
annually thereafter. An insurer may not deny to an insured | ||
eligibility, or continued eligibility, to enroll or to renew | ||
coverage under the terms of the plan solely for the purpose of | ||
avoiding the requirements of this Section. An insurer may not | ||
penalize or reduce or limit the reimbursement of an attending | ||
provider or provide incentives (monetary or otherwise) to an | ||
attending provider to induce the provider to provide care to | ||
an insured in a manner inconsistent with this Section. | ||
(c) 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. | ||
(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20 .) |
Section 20. The Health Maintenance Organization Act is | ||
amended by changing Sections 4-6.1 and 5-3 as follows: | ||
(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7) | ||
Sec. 4-6.1. Mammograms; mastectomies. | ||
(a) Every contract or evidence of coverage issued by a | ||
Health Maintenance Organization for persons who are residents | ||
of this State shall contain coverage for screening by low-dose | ||
mammography for all patients women 35 years of age or older for | ||
the presence of occult breast cancer. The coverage shall be as | ||
follows: | ||
(1) A baseline mammogram for patients women 35 to 39 | ||
years of age. | ||
(2) An annual mammogram for patients women 40 years of | ||
age or older. | ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the patient's woman's health care | ||
provider for patients 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. | ||
(4) For an individual or group policy of accident and | ||
health insurance or a managed care plan that is amended, | ||
delivered, issued, or renewed on or after January 1, 2020 | ||
( the effective date of Public Act 101-580) and before the | ||
effective date of this amendatory Act of the 103rd General |
Assembly this amendatory Act of the 101st General | ||
Assembly , 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. | ||
(4.3) For an individual or group policy of accident | ||
and health insurance or a managed care plan that is | ||
amended, delivered, issued, or renewed on or after the | ||
effective date of this amendatory Act of the 103rd General | ||
Assembly, 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, advanced | ||
practice registered nurse, or physician assistant. | ||
(4.5) For a group policy of accident and health | ||
insurance that is amended, delivered, issued, or renewed | ||
on or after the effective date of this amendatory Act of | ||
the 103rd General Assembly, molecular breast imaging (MBI) | ||
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, advanced | ||
practice registered nurse, or physician assistant. | ||
(5) For an individual or group policy of accident and |
health insurance or a managed care plan that is amended, | ||
delivered, issued, or renewed on or after January 1, 2020 | ||
( the effective date of Public Act 101-580) this amendatory | ||
Act of the 101st General Assembly , 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. | ||
A policy subject to this subsection shall not impose a | ||
deductible, coinsurance, copayment, or any other cost-sharing | ||
requirement on the coverage provided; 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). | ||
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 radiation exposure delivery of less than | ||
1 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 | ||
subsection, 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 subsection. | ||
(a-5) Coverage as described in subsection (a) shall be |
provided at no cost to the enrollee and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(b) No contract or evidence of coverage issued by a health | ||
maintenance organization that provides for the surgical | ||
procedure known as a mastectomy shall be issued, amended, | ||
delivered, or renewed in this State on or after July 3, 2001 | ||
( the effective date of Public Act 92-0048) this amendatory Act | ||
of the 92nd General Assembly unless that coverage also | ||
provides for prosthetic devices or reconstructive surgery | ||
incident to the mastectomy, providing that the mastectomy is | ||
performed after July 3, 2001 the effective date of this | ||
amendatory Act . Coverage for breast reconstruction in | ||
connection with a mastectomy shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the | ||
mastectomy and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no |
evidence of malignancy, then the offered coverage may be | ||
limited to the provision of prosthetic devices and | ||
reconstructive surgery to within 2 years after the date of the | ||
mastectomy. As used in this Section, "mastectomy" means the | ||
removal of all or part of the breast for medically necessary | ||
reasons, as determined by a licensed physician. | ||
Written notice of the availability of coverage under this | ||
Section shall be delivered to the enrollee upon enrollment and | ||
annually thereafter. A health maintenance organization may not | ||
deny to an enrollee eligibility, or continued eligibility, to | ||
enroll or to renew coverage under the terms of the plan solely | ||
for the purpose of avoiding the requirements of this Section. | ||
A health maintenance organization may not penalize or reduce | ||
or limit the reimbursement of an attending provider or provide | ||
incentives (monetary or otherwise) to an attending provider to | ||
induce the provider to provide care to an insured in a manner | ||
inconsistent with this Section. | ||
(c) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, 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. | ||
(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20 .) |
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||
Sec. 5-3. Insurance Code provisions. | ||
(a) Health Maintenance Organizations shall be subject to | ||
the provisions of Sections 133, 134, 136, 137, 139, 140, | ||
141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | ||
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | ||
355.2, 355.3, 355b, 355c, 356f, 356g, 356g.5-1, 356m, 356q, | ||
356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||
356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||
356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||
356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||
356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||
356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||
356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||
356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||
subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||
Illinois Insurance Code. | ||
(b) For purposes of the Illinois Insurance Code, except | ||
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||
Health Maintenance Organizations in the following categories | ||
are deemed to be "domestic companies": |
(1) a corporation authorized under the Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act; | ||
(2) a corporation organized under the laws of this | ||
State; or | ||
(3) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(c) In considering the merger, consolidation, or other | ||
acquisition of control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||
(1) the Director shall give primary consideration to | ||
the continuation of benefits to enrollees and the | ||
financial conditions of the acquired Health Maintenance | ||
Organization after the merger, consolidation, or other | ||
acquisition of control takes effect; | ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making his determination | ||
with respect to the merger, consolidation, or other | ||
acquisition of control, need not take into account the | ||
effect on competition of the merger, consolidation, or | ||
other acquisition of control; | ||
(3) the Director shall have the power to require the |
following information: | ||
(A) certification by an independent actuary of the | ||
adequacy of the reserves of the Health Maintenance | ||
Organization sought to be acquired; | ||
(B) pro forma financial statements reflecting the | ||
combined balance sheets of the acquiring company and | ||
the Health Maintenance Organization sought to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days prior to the acquisition, as well as pro | ||
forma financial statements reflecting projected | ||
combined operation for a period of 2 years; | ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with respect to the operation | ||
of the Health Maintenance Organization sought to be | ||
acquired for a period of not less than 3 years; and | ||
(D) such other information as the Director shall | ||
require. | ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code and this Section 5-3 shall apply to the sale by | ||
any health maintenance organization of greater than 10% of its | ||
enrollee population (including , without limitation , the health | ||
maintenance organization's right, title, and interest in and | ||
to its health care certificates). | ||
(e) In considering any management contract or service | ||
agreement subject to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in addition to the criteria |
specified in Section 141.2 of the Illinois Insurance Code, | ||
take into account the effect of the management contract or | ||
service agreement on the continuation of benefits to enrollees | ||
and the financial condition of the health maintenance | ||
organization to be managed or serviced, and (ii) need not take | ||
into account the effect of the management contract or service | ||
agreement on competition. | ||
(f) Except for small employer groups as defined in the | ||
Small Employer Rating, Renewability and Portability Health | ||
Insurance Act and except for medicare supplement policies as | ||
defined in Section 363 of the Illinois Insurance Code, a | ||
Health Maintenance Organization may by contract agree with a | ||
group or other enrollment unit to effect refunds or charge | ||
additional premiums under the following terms and conditions: | ||
(i) the amount of, and other terms and conditions with | ||
respect to, the refund or additional premium are set forth | ||
in the group or enrollment unit contract agreed in advance | ||
of the period for which a refund is to be paid or | ||
additional premium is to be charged (which period shall | ||
not be less than one year); and | ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20% of the Health Maintenance | ||
Organization's profitable or unprofitable experience with | ||
respect to the group or other enrollment unit for the | ||
period (and, for purposes of a refund or additional | ||
premium, the profitable or unprofitable experience shall |
be calculated taking into account a pro rata share of the | ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but shall not include any refund to be | ||
made or additional premium to be paid pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the group or enrollment unit may agree that the profitable | ||
or unprofitable experience may be calculated taking into | ||
account the refund period and the immediately preceding 2 | ||
plan years. | ||
The Health Maintenance Organization shall include a | ||
statement in the evidence of coverage issued to each enrollee | ||
describing the possibility of a refund or additional premium, | ||
and upon request of any group or enrollment unit, provide to | ||
the group or enrollment unit a description of the method used | ||
to calculate (1) the Health Maintenance Organization's | ||
profitable experience with respect to the group or enrollment | ||
unit and the resulting refund to the group or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable | ||
experience with respect to the group or enrollment unit and | ||
the resulting additional premium to be paid by the group or | ||
enrollment unit. | ||
In no event shall the Illinois Health Maintenance | ||
Organization Guaranty Association be liable to pay any | ||
contractual obligation of an insolvent organization to pay any | ||
refund authorized under this Section. | ||
(g) 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. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 25. The Illinois Public Aid Code is amended by | ||
changing Section 5-5 as follows: | ||
(305 ILCS 5/5-5) | ||
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 individuals, 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 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, 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. | ||
On and after January 1, 2022, the Department of Healthcare | ||
and Family Services shall administer and regulate a | ||
school-based dental program that allows for the out-of-office | ||
delivery of preventative dental services in a school setting | ||
to children under 19 years of age. The Department shall | ||
establish, by rule, guidelines for participation by providers | ||
and set requirements for follow-up referral care based on the |
requirements established in the Dental Office Reference Manual | ||
published by the Department that establishes the requirements | ||
for dentists participating in the All Kids Dental School | ||
Program. Every effort shall be made by the Department when | ||
developing the program requirements to consider the different | ||
geographic differences of both urban and rural areas of the | ||
State for initial treatment and necessary follow-up care. No | ||
provider shall be charged a fee by any unit of local government | ||
to participate in the school-based dental program administered | ||
by the Department. Nothing in this paragraph shall be | ||
construed to limit or preempt a home rule unit's or school | ||
district's authority to establish, change, or administer a | ||
school-based dental program in addition to, or independent of, | ||
the school-based dental program administered by the | ||
Department. | ||
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 | ||
individuals 35 years of age or older who are eligible for | ||
medical assistance under this Article, as follows: | ||
(A) A baseline mammogram for individuals 35 to 39 | ||
years of age. | ||
(B) An annual mammogram for individuals 40 years of | ||
age or older. | ||
(C) A mammogram at the age and intervals considered | ||
medically necessary by the individual's health care | ||
provider for individuals 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. | ||
(G) Molecular breast imaging (MBI) 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, 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 and, after | ||
January 1, 2023 (the effective date of Public Act 102-1018), | ||
breast tomosynthesis. | ||
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 radiologists that are trained in all forms | ||
of FDA approved breast imaging technologies, 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 | ||
individuals 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. | ||
The Department shall provide coverage and reimbursement | ||
for a human papillomavirus (HPV) vaccine that is approved for |
marketing by the federal Food and Drug Administration for all | ||
persons between the ages of 9 and 45. Subject to federal | ||
approval, the Department shall provide coverage and | ||
reimbursement for a human papillomavirus (HPV) vaccine for | ||
persons of the age of 46 and above who have been diagnosed with | ||
cervical dysplasia with a high risk of recurrence or | ||
progression. The Department shall disallow any | ||
preauthorization requirements for the administration of the | ||
human papillomavirus (HPV) vaccine. | ||
On or after July 1, 2022, individuals who are otherwise | ||
eligible for medical assistance under this Article shall | ||
receive coverage for perinatal depression screenings for the | ||
12-month period beginning on the last day of their pregnancy. | ||
Medical assistance coverage under this paragraph shall be | ||
conditioned on the use of a screening instrument approved by | ||
the Department. | ||
Any medical or health care provider shall immediately | ||
recommend, to any pregnant individual 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 individuals under this Code shall receive information | ||
from the Department on the availability of services under any | ||
program providing case management services for addicted | ||
individuals, including information on appropriate referrals | ||
for other social services that may be needed by addicted | ||
individuals 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 the recipient's 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 the 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 120 | ||
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-adjudicated , 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 the 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 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 or hospital fees related to the dispensing, distribution, | ||
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. The | ||
Department shall not impose a copayment on the coverage | ||
provided for naloxone hydrochloride under the medical | ||
assistance program. | ||
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. | ||
Within 90 days after October 8, 2021 (the effective date | ||
of Public Act 102-665), the Department shall seek federal | ||
approval of a State Plan amendment to expand coverage for | ||
family planning services that includes presumptive eligibility | ||
to individuals whose income is at or below 208% of the federal | ||
poverty level. Coverage under this Section shall be effective | ||
beginning no later than December 1, 2022. | ||
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. | ||
Notwithstanding any other provision of this Code, | ||
community-based pediatric palliative care from a trained | ||
interdisciplinary team shall be covered under the medical | ||
assistance program as provided in Section 15 of the Pediatric | ||
Palliative Care Act. | ||
Notwithstanding any other provision of this Code, within | ||
12 months after June 2, 2022 (the effective date of Public Act | ||
102-1037) and subject to federal approval, acupuncture | ||
services performed by an acupuncturist licensed under the | ||
Acupuncture Practice Act who is acting within the scope of his | ||
or her license shall be covered under the medical assistance | ||
program. The Department shall apply for any federal waiver or | ||
State Plan amendment, if required, to implement this | ||
paragraph. The Department may adopt any rules, including | ||
standards and criteria, necessary to implement this paragraph. | ||
Notwithstanding any other provision of this Code, the | ||
medical assistance program shall, subject to appropriation and | ||
federal approval, reimburse hospitals for costs associated | ||
with a newborn screening test for the presence of | ||
metachromatic leukodystrophy, as required under the Newborn | ||
Metabolic Screening Act, at a rate not less than the fee |
charged by the Department of Public Health. The Department | ||
shall seek federal approval before the implementation of the | ||
newborn screening test fees by the Department of Public | ||
Health. | ||
Notwithstanding any other provision of this Code, | ||
beginning on January 1, 2024, subject to federal approval, | ||
cognitive assessment and care planning services provided to a | ||
person who experiences signs or symptoms of cognitive | ||
impairment, as defined by the Diagnostic and Statistical | ||
Manual of Mental Disorders, Fifth Edition, 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, | ||
medically necessary reconstructive services that are intended | ||
to restore physical appearance shall be covered under the | ||
medical assistance program for persons who are otherwise | ||
eligible for medical assistance under this Article. As used in | ||
this paragraph, "reconstructive services" means treatments | ||
performed on structures of the body damaged by trauma to | ||
restore physical appearance. | ||
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; | ||
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article | ||
55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, | ||
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; | ||
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. | ||
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; |
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. | ||
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; | ||
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. | ||
1-1-24; revised 12-15-23.) | ||
Section 99. Effective date. This Act takes effect January | ||
1, 2026. |