Sen. Cristina Castro

Filed: 4/5/2019

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1909

2    AMENDMENT NO. ______. Amend Senate Bill 1909, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 1. This Act may be referred to as the Improving
6Health Care for Pregnant and Postpartum Individuals Act.
 
7    Section 5. The State Employees Group Insurance Act of 1971
8is amended by changing Section 6.11 as follows:
 
9    (5 ILCS 375/6.11)
10    (Text of Section before amendment by P.A. 100-1170)
11    Sec. 6.11. Required health benefits; Illinois Insurance
12Code requirements. The program of health benefits shall provide
13the post-mastectomy care benefits required to be covered by a
14policy of accident and health insurance under Section 356t of
15the Illinois Insurance Code. The program of health benefits

 

 

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1shall provide the coverage required under Sections 356g,
2356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
3356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
4356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and
5356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
6The program of health benefits must comply with Sections
7155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 of the
8Illinois Insurance Code. The Department of Insurance shall
9enforce the requirements of this Section.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
17100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
181-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
191-8-19.)
 
20    (Text of Section after amendment by P.A. 100-1170)
21    Sec. 6.11. Required health benefits; Illinois Insurance
22Code requirements. The program of health benefits shall provide
23the post-mastectomy care benefits required to be covered by a
24policy of accident and health insurance under Section 356t of
25the Illinois Insurance Code. The program of health benefits

 

 

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1shall provide the coverage required under Sections 356g,
2356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
3356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
4356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29,
5and 356z.32, and 356z.33 of the Illinois Insurance Code. The
6program of health benefits must comply with Sections 155.22a,
7155.37, 355b, 356z.19, 370c, and 370c.1 of the Illinois
8Insurance Code. The Department of Insurance shall enforce the
9requirements of this Section with respect to Sections 370c and
10370c.1 of the Illinois Insurance Code; all other requirements
11of this Section shall be enforced by the Department of Central
12Management Services.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
20100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
211-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19;
22100-1170, eff. 6-1-19.)
 
23    Section 10. The Department of Human Services Act is amended
24by adding Sections 10-23 and 10-24 as follows:
 

 

 

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1    (20 ILCS 1305/10-23 new)
2    Sec. 10-23. High-risk pregnant or postpartum women. The
3Department shall expand and update its maternal child health
4programs to serve any pregnant or postpartum woman identified
5as high-risk by her primary care provider or hospital according
6to standards developed by the Department of Public Health under
7Section 3 of the Developmental Disability Prevention Act. The
8services shall be provided by registered nurses, licensed
9social workers, or other staff with behavioral health or
10medical training, as approved by the Department. The persons
11providing the services may collaborate with other providers,
12including, but not limited to, obstetricians, gynecologists,
13or pediatricians, when providing services to a patient.
 
14    (20 ILCS 1305/10-24 new)
15    Sec. 10-24. Nurse-Family Partnership Pilot Program.
16Subject to the availability of funds provided for this purpose
17by public or private sources, the Department may, in its
18discretion, establish an evidence-based, voluntary, nurse home
19visitation program that improves the health and well-being of
20low-income, first-time pregnant women and their children. The
21program shall be known as the Nurse-Family Partnership Pilot
22Program and shall include, but not be limited to, the following
23components:
24        (1) Eligibility criteria. Program participants must be
25    first-time pregnant women who have yet to reach the 28th

 

 

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1    week of pregnancy and who are eligible for medical
2    assistance under Article V of the Illinois Public Aid Code.
3        (2) Maternal health education. Registered nurses shall
4    make home visits to program participants and shall provide
5    education, support, and guidance regarding pregnancy and
6    maternal health, child health and development, parenting,
7    the mother's life course development, and instruction on
8    how to identify and use family and community supports.
9        (3) Pre-natal and post-natal care. Home visits to
10    program participants shall begin before their 28th week of
11    pregnancy and shall continue on a weekly or biweekly basis
12    until their children reach the age of 2.
 
13    Section 15. The Department of Public Health Powers and
14Duties Law of the Civil Administrative Code of Illinois is
15amended by adding Section 2310-455 as follows:
 
16    (20 ILCS 2310/2310-455 new)
17    Sec. 2310-455. High Risk Infant Follow-up. The Department,
18in collaboration with the Department of Human Services, the
19Department of Healthcare and Family Services, and other key
20providers of maternal child health services, shall revise or
21add to the rules of the Maternal and Child Health Services Code
22(77 Ill. Adm. Code 630) that govern the High Risk Infant
23Follow-up, using current scientific and national and State
24outcomes data, to expand existing services to improve both

 

 

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1maternal and infant outcomes overall and to reduce racial
2disparities in outcomes and services provided. The rules shall
3be revised or adopted on or before June 1, 2021.
 
4    Section 20. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and 356z.29,
16356z.32, and 356z.33 of the Illinois Insurance Code. The
17coverage shall comply with Sections 155.22a, 355b, 356z.19, and
18370c of the Illinois Insurance Code. The Department of
19Insurance shall enforce the requirements of this Section. The
20requirement that health benefits be covered as provided in this
21Section is an exclusive power and function of the State and is
22a denial and limitation under Article VII, Section 6,
23subsection (h) of the Illinois Constitution. A home rule county
24to which this Section applies must comply with every provision

 

 

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1of this Section.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
9100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
101-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
1110-3-18.)
 
12    Section 25. The Illinois Municipal Code is amended by
13changing Section 10-4-2.3 as follows:
 
14    (65 ILCS 5/10-4-2.3)
15    Sec. 10-4-2.3. Required health benefits. If a
16municipality, including a home rule municipality, is a
17self-insurer for purposes of providing health insurance
18coverage for its employees, the coverage shall include coverage
19for the post-mastectomy care benefits required to be covered by
20a policy of accident and health insurance under Section 356t
21and the coverage required under Sections 356g, 356g.5,
22356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
23356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25,
24and 356z.26, and 356z.29, 356z.32, and 356z.33 of the Illinois

 

 

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1Insurance Code. The coverage shall comply with Sections
2155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
3Code. The Department of Insurance shall enforce the
4requirements of this Section. The requirement that health
5benefits be covered as provided in this is an exclusive power
6and function of the State and is a denial and limitation under
7Article VII, Section 6, subsection (h) of the Illinois
8Constitution. A home rule municipality to which this Section
9applies must comply with every provision of this Section.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
17100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
181-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
1910-4-18.)
 
20    Section 30. The School Code is amended by changing Section
2110-22.3f as follows:
 
22    (105 ILCS 5/10-22.3f)
23    Sec. 10-22.3f. Required health benefits. Insurance
24protection and benefits for employees shall provide the

 

 

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1post-mastectomy care benefits required to be covered by a
2policy of accident and health insurance under Section 356t and
3the coverage required under Sections 356g, 356g.5, 356g.5-1,
4356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
5356z.13, 356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and
6356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
7Insurance policies shall comply with Section 356z.19 of the
8Illinois Insurance Code. The coverage shall comply with
9Sections 155.22a, 355b, and 370c of the Illinois Insurance
10Code. The Department of Insurance shall enforce the
11requirements of this Section.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
19100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
201-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
 
21    Section 35. The Illinois Insurance Code is amended by
22adding Sections 356z.4a and 356z.33 as follows:
 
23    (215 ILCS 5/356z.4a new)
24    Sec. 356z.4a. Billing for long-acting reversible

 

 

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1contraceptives.
2    (a) "Long-acting reversible contraceptive device" means
3any intrauterine device or contraceptive implant.
4    (b) Any group health insurance policy, individual health
5policy, group policy of accident and health insurance, group
6health benefit plan, or qualified health plan that is offered
7through the health insurance marketplace, a small employer
8group health plan, or a large employer group health plan that
9is amended, delivered, issued, or renewed on or after the
10effective date of this amendatory Act of the 101st General
11Assembly shall allow hospitals separate reimbursement for a
12long-acting reversible contraceptive device provided
13immediately postpartum in the inpatient hospital setting
14before hospital discharge. The payment shall be made in
15addition to a bundled or Diagnostic Related Group reimbursement
16for labor and delivery.
 
17    (215 ILCS 5/356z.33 new)
18    Sec. 356z.33. Pregnancy and postpartum coverage.
19    (a) A group health insurance policy, individual health
20policy, group policy of accident and health insurance, group
21health benefit plan, qualified health plan that is offered
22through the health insurance marketplace, small employer group
23health plan, or large employer group health plan that is
24amended, delivered, issued, or renewed on or after the
25effective date of this amendatory Act of the 101st General

 

 

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1Assembly shall provide coverage for medically necessary
2treatment for postpartum complications, including, but not
3limited to, infection, depression, and hemorrhaging, up to one
4year after the woman has given birth to a child as set forth in
5this Section and consistent with other Sections of this Code,
6including, but not limited to, Sections 370c and 370c.1. The
7coverage under this Section shall be subject to other general
8exclusions, limitations, and financial requirements of the
9policy, including coordination of benefits, participating
10provider requirements, and utilization review of health care
11services, including review of medical necessity, case
12management, experimental and investigational treatments,
13managed care provisions, and other terms and conditions.
14    (b) A group health insurance policy, individual health
15policy, group policy of accident and health insurance, group
16health benefit plan, qualified health plan that is offered
17through the health insurance marketplace, small employer group
18health plan, or large employer group health plan that is
19amended, delivered, issued, or renewed on or after the
20effective date of this amendatory Act of the 101st General
21Assembly shall provide coverage for medically necessary
22treatment of mental, emotional, nervous, or substance use
23disorder or conditions at in-network facilities for a pregnant
24or postpartum woman up to one year after giving birth to a
25child consistent with the requirements set forth in this
26Section and in Sections 370c and 370c.1 of this Code. The

 

 

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1services for the treatment of mental, emotional, nervous, or
2substance use disorder or condition shall be prescribed or
3ordered by a licensed physician, licensed psychologist,
4licensed psychiatrist, or licensed advanced practice
5registered nurse and provided by licensed health care
6professionals or licensed or certified mental, emotional,
7nervous, or substance use disorder or conditions providers in
8licensed, certified, or otherwise State-approved facilities.
9    As used in this subsection (b), "provider" includes
10licensed physicians, licensed psychologists, licensed
11psychiatrists, licensed advanced practice registered nurses,
12and licensed and certified mental, emotional, nervous, and
13substance use disorder and conditions providers.
14    Benefits under this subsection (b) shall be as follows:
15        (1) The benefits provided for inpatient and outpatient
16    services for the treatment of mental, emotional, nervous,
17    or substance use disorder or conditions related to
18    pregnancy or postpartum complications shall be provided
19    when determined to be medically necessary consistent with
20    the requirements of Sections 370c and 370c.1 of this Code.
21    The facility or provider shall notify the insurer of both
22    the admission and the initial treatment plan within 48
23    hours after admission or initiation of treatment. Nothing
24    shall prevent an insurer from applying concurrent and
25    post-service utilization review of health care services,
26    including review of medical necessity, case management,

 

 

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1    experimental and investigational treatments, managed care
2    provisions, and other terms and conditions of the insurance
3    policy.
4        (2) The benefits for the first 48 hours of initiation
5    of services for an inpatient admission,
6    detoxification/withdrawal management program, or a partial
7    hospitalization admission for the treatment of mental,
8    emotional, nervous, or substance use disorder or
9    conditions related to pregnancy or postpartum
10    complications shall be provided without post-service or
11    concurrent review of medical necessity, as the medical
12    necessity for the first 48 hours of such services shall be
13    determined solely by the covered pregnant or postpartum
14    woman's provider. Nothing shall prevent an insurer from
15    applying concurrent and post-service utilization review,
16    including the review of medical necessity, case
17    management, experimental and investigational treatments,
18    managed care provisions, and other terms and conditions of
19    the insurance policy of any inpatient admission,
20    detoxification/withdrawal management program admission, or
21    a partial hospitalization admission services for the
22    treatment of mental emotional, nervous, or substance use
23    disorder or conditions related to pregnancy or postpartum
24    complications received 48 hours after the initiation of
25    such services. If an insurer determines that the services
26    are no longer medically necessary, then the covered person

 

 

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1    shall have the right to external review pursuant to the
2    requirements of the Health Carrier External Review Act.
3        (3) If an insurer determines that continued inpatient
4    care, detoxification/withdrawal management, partial
5    hospitalization, intensive outpatient treatment, or
6    outpatient treatment in a facility is no longer medically
7    necessary, the insurer shall, within 24 hours, provide
8    written notice to the covered pregnant or postpartum woman
9    and the covered pregnant or postpartum woman's provider of
10    its decision and the right to file an expedited internal
11    appeal of the determination. The insurer shall review and
12    make a determination with respect to the internal appeal
13    within 24 hours and communicate such determination to the
14    covered pregnant or postpartum woman and the covered
15    pregnant or postpartum woman's provider. If the
16    determination is to uphold the denial, the covered pregnant
17    or postpartum woman and the covered pregnant or postpartum
18    woman's provider have the right to file an expedited
19    external appeal. An independent utilization review
20    organization shall make a determination within 72 hours. If
21    the insurer's determination is upheld and it is determined
22    continued inpatient care, detoxification/withdrawal
23    management, partial hospitalization, intensive outpatient
24    treatment, or outpatient treatment is not medically
25    necessary, the insurer shall remain responsible to provide
26    benefits for the inpatient care, detoxification/withdrawal

 

 

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1    management, partial hospitalization, intensive outpatient
2    treatment, or outpatient treatment through the day
3    following the date the determination is made and the
4    covered pregnant or postpartum woman shall only be
5    responsible for any applicable copayment, deductible, and
6    coinsurance for the stay through that date as applicable
7    under the policy. The covered pregnant or postpartum woman
8    shall not be discharged or released from the inpatient
9    facility, detoxification/withdrawal management, partial
10    hospitalization, intensive outpatient treatment, or
11    outpatient treatment until all internal appeals and
12    independent utilization review organization appeals are
13    exhausted. A decision to reverse an adverse determination
14    shall comply with the Health Carrier External Review Act.
15        (4) Except as otherwise stated in this subsection (b),
16    the benefits and cost-sharing shall be provided to the same
17    extent as for any other medical condition covered under the
18    policy.
19        (5) The benefits required by this subsection (b) are to
20    be provided to all covered pregnant or postpartum woman
21    with a diagnosis of mental, emotional, nervous, or
22    substance use disorder or conditions. The presence of
23    additional related or unrelated diagnoses shall not be a
24    basis to reduce or deny the benefits required by this
25    subsection (b).
26    (c) A group health insurance policy, individual health

 

 

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1policy, group policy of accident and health insurance, group
2health benefit plan, qualified health plan that is offered
3through the health insurance marketplace, small employer group
4health plan, or large employer group health plan that is
5amended, delivered, issued, executed, or renewed in this State
6or approved for issuance or renewal in this State on or after
7the effective date of this amendatory Act of the 101st General
8Assembly shall provide coverage for case management and
9outreach for a postpartum woman that had a high-risk pregnancy.
10The coverage under this subsection (c) shall take into
11consideration the cultural differences of the covered
12postpartum woman in case coordination. As used in this
13subsection (c), "high-risk pregnancy" means a pregnancy in
14which the mother or baby is at increased risk for poor health
15or complications during pregnancy or childbirth.
 
16    Section 40. The Health Maintenance Organization Act is
17amended by changing Section 5-3 as follows:
 
18    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
19    Sec. 5-3. Insurance Code provisions.
20    (a) Health Maintenance Organizations shall be subject to
21the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
22141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
23154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
24355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,

 

 

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1356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
2356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
3356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33,
4364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
5368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,
6409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
7Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
8XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
9    (b) For purposes of the Illinois Insurance Code, except for
10Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
11Maintenance Organizations in the following categories are
12deemed to be "domestic companies":
13        (1) a corporation authorized under the Dental Service
14    Plan Act or the Voluntary Health Services Plans Act;
15        (2) a corporation organized under the laws of this
16    State; or
17        (3) a corporation organized under the laws of another
18    state, 30% or more of the enrollees of which are residents
19    of this State, except a corporation subject to
20    substantially the same requirements in its state of
21    organization as is a "domestic company" under Article VIII
22    1/2 of the Illinois Insurance Code.
23    (c) In considering the merger, consolidation, or other
24acquisition of control of a Health Maintenance Organization
25pursuant to Article VIII 1/2 of the Illinois Insurance Code,
26        (1) the Director shall give primary consideration to

 

 

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1    the continuation of benefits to enrollees and the financial
2    conditions of the acquired Health Maintenance Organization
3    after the merger, consolidation, or other acquisition of
4    control takes effect;
5        (2)(i) the criteria specified in subsection (1)(b) of
6    Section 131.8 of the Illinois Insurance Code shall not
7    apply and (ii) the Director, in making his determination
8    with respect to the merger, consolidation, or other
9    acquisition of control, need not take into account the
10    effect on competition of the merger, consolidation, or
11    other acquisition of control;
12        (3) the Director shall have the power to require the
13    following information:
14            (A) certification by an independent actuary of the
15        adequacy of the reserves of the Health Maintenance
16        Organization sought to be acquired;
17            (B) pro forma financial statements reflecting the
18        combined balance sheets of the acquiring company and
19        the Health Maintenance Organization sought to be
20        acquired as of the end of the preceding year and as of
21        a date 90 days prior to the acquisition, as well as pro
22        forma financial statements reflecting projected
23        combined operation for a period of 2 years;
24            (C) a pro forma business plan detailing an
25        acquiring party's plans with respect to the operation
26        of the Health Maintenance Organization sought to be

 

 

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1        acquired for a period of not less than 3 years; and
2            (D) such other information as the Director shall
3        require.
4    (d) The provisions of Article VIII 1/2 of the Illinois
5Insurance Code and this Section 5-3 shall apply to the sale by
6any health maintenance organization of greater than 10% of its
7enrollee population (including without limitation the health
8maintenance organization's right, title, and interest in and to
9its health care certificates).
10    (e) In considering any management contract or service
11agreement subject to Section 141.1 of the Illinois Insurance
12Code, the Director (i) shall, in addition to the criteria
13specified in Section 141.2 of the Illinois Insurance Code, take
14into account the effect of the management contract or service
15agreement on the continuation of benefits to enrollees and the
16financial condition of the health maintenance organization to
17be managed or serviced, and (ii) need not take into account the
18effect of the management contract or service agreement on
19competition.
20    (f) Except for small employer groups as defined in the
21Small Employer Rating, Renewability and Portability Health
22Insurance Act and except for medicare supplement policies as
23defined in Section 363 of the Illinois Insurance Code, a Health
24Maintenance Organization may by contract agree with a group or
25other enrollment unit to effect refunds or charge additional
26premiums under the following terms and conditions:

 

 

10100SB1909sam004- 20 -LRB101 09278 CPF 59162 a

1        (i) the amount of, and other terms and conditions with
2    respect to, the refund or additional premium are set forth
3    in the group or enrollment unit contract agreed in advance
4    of the period for which a refund is to be paid or
5    additional premium is to be charged (which period shall not
6    be less than one year); and
7        (ii) the amount of the refund or additional premium
8    shall not exceed 20% of the Health Maintenance
9    Organization's profitable or unprofitable experience with
10    respect to the group or other enrollment unit for the
11    period (and, for purposes of a refund or additional
12    premium, the profitable or unprofitable experience shall
13    be calculated taking into account a pro rata share of the
14    Health Maintenance Organization's administrative and
15    marketing expenses, but shall not include any refund to be
16    made or additional premium to be paid pursuant to this
17    subsection (f)). The Health Maintenance Organization and
18    the group or enrollment unit may agree that the profitable
19    or unprofitable experience may be calculated taking into
20    account the refund period and the immediately preceding 2
21    plan years.
22    The Health Maintenance Organization shall include a
23statement in the evidence of coverage issued to each enrollee
24describing the possibility of a refund or additional premium,
25and upon request of any group or enrollment unit, provide to
26the group or enrollment unit a description of the method used

 

 

10100SB1909sam004- 21 -LRB101 09278 CPF 59162 a

1to calculate (1) the Health Maintenance Organization's
2profitable experience with respect to the group or enrollment
3unit and the resulting refund to the group or enrollment unit
4or (2) the Health Maintenance Organization's unprofitable
5experience with respect to the group or enrollment unit and the
6resulting additional premium to be paid by the group or
7enrollment unit.
8    In no event shall the Illinois Health Maintenance
9Organization Guaranty Association be liable to pay any
10contractual obligation of an insolvent organization to pay any
11refund authorized under this Section.
12    (g) Rulemaking authority to implement Public Act 95-1045,
13if any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
19100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff.
208-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
2110-4-18.)
 
22    Section 45. The Voluntary Health Services Plans Act is
23amended by changing Section 10 as follows:
 
24    (215 ILCS 165/10)  (from Ch. 32, par. 604)

 

 

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1    Sec. 10. Application of Insurance Code provisions. Health
2services plan corporations and all persons interested therein
3or dealing therewith shall be subject to the provisions of
4Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
5143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
6356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
7356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
8356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
9356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
10356z.32, 356z.33, 364.01, 367.2, 368a, 401, 401.1, 402, 403,
11403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
12Section 367 of the Illinois Insurance Code.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
20100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
211-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
 
22    Section 50. The Illinois Public Aid Code is amended by
23changing Sections 5-2, 5-5, and 5-5.24 and by adding Section
245-5.27 as follows:
 

 

 

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1    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
2    Sec. 5-2. Classes of Persons Eligible.
3    Medical assistance under this Article shall be available to
4any of the following classes of persons in respect to whom a
5plan for coverage has been submitted to the Governor by the
6Illinois Department and approved by him. If changes made in
7this Section 5-2 require federal approval, they shall not take
8effect until such approval has been received:
9        1. Recipients of basic maintenance grants under
10    Articles III and IV.
11        2. Beginning January 1, 2014, persons otherwise
12    eligible for basic maintenance under Article III,
13    excluding any eligibility requirements that are
14    inconsistent with any federal law or federal regulation, as
15    interpreted by the U.S. Department of Health and Human
16    Services, but who fail to qualify thereunder on the basis
17    of need, and who have insufficient income and resources to
18    meet the costs of necessary medical care, including but not
19    limited to the following:
20            (a) All persons otherwise eligible for basic
21        maintenance under Article III but who fail to qualify
22        under that Article on the basis of need and who meet
23        either of the following requirements:
24                (i) their income, as determined by the
25            Illinois Department in accordance with any federal
26            requirements, is equal to or less than 100% of the

 

 

10100SB1909sam004- 24 -LRB101 09278 CPF 59162 a

1            federal poverty level; or
2                (ii) their income, after the deduction of
3            costs incurred for medical care and for other types
4            of remedial care, is equal to or less than 100% of
5            the federal poverty level.
6            (b) (Blank).
7        3. (Blank).
8        4. Persons not eligible under any of the preceding
9    paragraphs who fall sick, are injured, or die, not having
10    sufficient money, property or other resources to meet the
11    costs of necessary medical care or funeral and burial
12    expenses.
13        5.(a) Women during pregnancy and during the 12-month
14    60-day period beginning on the last day of the pregnancy,
15    together with their infants, whose income is at or below
16    200% of the federal poverty level. Until September 30,
17    2019, or sooner if the maintenance of effort requirements
18    under the Patient Protection and Affordable Care Act are
19    eliminated or may be waived before then, women during
20    pregnancy and during the 12-month 60-day period beginning
21    on the last day of the pregnancy, whose countable monthly
22    income, after the deduction of costs incurred for medical
23    care and for other types of remedial care as specified in
24    administrative rule, is equal to or less than the Medical
25    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
26    on April 1, 2013 as set forth in administrative rule.

 

 

10100SB1909sam004- 25 -LRB101 09278 CPF 59162 a

1        (b) The plan for coverage shall provide ambulatory
2    prenatal care to pregnant women during a presumptive
3    eligibility period and establish an income eligibility
4    standard that is equal to 200% of the federal poverty
5    level, provided that costs incurred for medical care are
6    not taken into account in determining such income
7    eligibility.
8        (c) The Illinois Department may conduct a
9    demonstration in at least one county that will provide
10    medical assistance to pregnant women, together with their
11    infants and children up to one year of age, where the
12    income eligibility standard is set up to 185% of the
13    nonfarm income official poverty line, as defined by the
14    federal Office of Management and Budget. The Illinois
15    Department shall seek and obtain necessary authorization
16    provided under federal law to implement such a
17    demonstration. Such demonstration may establish resource
18    standards that are not more restrictive than those
19    established under Article IV of this Code.
20        6. (a) Children younger than age 19 when countable
21    income is at or below 133% of the federal poverty level.
22    Until September 30, 2019, or sooner if the maintenance of
23    effort requirements under the Patient Protection and
24    Affordable Care Act are eliminated or may be waived before
25    then, children younger than age 19 whose countable monthly
26    income, after the deduction of costs incurred for medical

 

 

10100SB1909sam004- 26 -LRB101 09278 CPF 59162 a

1    care and for other types of remedial care as specified in
2    administrative rule, is equal to or less than the Medical
3    Assistance-No Grant(C) (MANG(C)) Income Standard in effect
4    on April 1, 2013 as set forth in administrative rule.
5        (b) Children and youth who are under temporary custody
6    or guardianship of the Department of Children and Family
7    Services or who receive financial assistance in support of
8    an adoption or guardianship placement from the Department
9    of Children and Family Services.
10        7. (Blank).
11        8. As required under federal law, persons who are
12    eligible for Transitional Medical Assistance as a result of
13    an increase in earnings or child or spousal support
14    received. The plan for coverage for this class of persons
15    shall:
16            (a) extend the medical assistance coverage to the
17        extent required by federal law; and
18            (b) offer persons who have initially received 6
19        months of the coverage provided in paragraph (a) above,
20        the option of receiving an additional 6 months of
21        coverage, subject to the following:
22                (i) such coverage shall be pursuant to
23            provisions of the federal Social Security Act;
24                (ii) such coverage shall include all services
25            covered under Illinois' State Medicaid Plan;
26                (iii) no premium shall be charged for such

 

 

10100SB1909sam004- 27 -LRB101 09278 CPF 59162 a

1            coverage; and
2                (iv) such coverage shall be suspended in the
3            event of a person's failure without good cause to
4            file in a timely fashion reports required for this
5            coverage under the Social Security Act and
6            coverage shall be reinstated upon the filing of
7            such reports if the person remains otherwise
8            eligible.
9        9. Persons with acquired immunodeficiency syndrome
10    (AIDS) or with AIDS-related conditions with respect to whom
11    there has been a determination that but for home or
12    community-based services such individuals would require
13    the level of care provided in an inpatient hospital,
14    skilled nursing facility or intermediate care facility the
15    cost of which is reimbursed under this Article. Assistance
16    shall be provided to such persons to the maximum extent
17    permitted under Title XIX of the Federal Social Security
18    Act.
19        10. Participants in the long-term care insurance
20    partnership program established under the Illinois
21    Long-Term Care Partnership Program Act who meet the
22    qualifications for protection of resources described in
23    Section 15 of that Act.
24        11. Persons with disabilities who are employed and
25    eligible for Medicaid, pursuant to Section
26    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,

 

 

10100SB1909sam004- 28 -LRB101 09278 CPF 59162 a

1    subject to federal approval, persons with a medically
2    improved disability who are employed and eligible for
3    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
4    the Social Security Act, as provided by the Illinois
5    Department by rule. In establishing eligibility standards
6    under this paragraph 11, the Department shall, subject to
7    federal approval:
8            (a) set the income eligibility standard at not
9        lower than 350% of the federal poverty level;
10            (b) exempt retirement accounts that the person
11        cannot access without penalty before the age of 59 1/2,
12        and medical savings accounts established pursuant to
13        26 U.S.C. 220;
14            (c) allow non-exempt assets up to $25,000 as to
15        those assets accumulated during periods of eligibility
16        under this paragraph 11; and
17            (d) continue to apply subparagraphs (b) and (c) in
18        determining the eligibility of the person under this
19        Article even if the person loses eligibility under this
20        paragraph 11.
21        12. Subject to federal approval, persons who are
22    eligible for medical assistance coverage under applicable
23    provisions of the federal Social Security Act and the
24    federal Breast and Cervical Cancer Prevention and
25    Treatment Act of 2000. Those eligible persons are defined
26    to include, but not be limited to, the following persons:

 

 

10100SB1909sam004- 29 -LRB101 09278 CPF 59162 a

1            (1) persons who have been screened for breast or
2        cervical cancer under the U.S. Centers for Disease
3        Control and Prevention Breast and Cervical Cancer
4        Program established under Title XV of the federal
5        Public Health Services Act in accordance with the
6        requirements of Section 1504 of that Act as
7        administered by the Illinois Department of Public
8        Health; and
9            (2) persons whose screenings under the above
10        program were funded in whole or in part by funds
11        appropriated to the Illinois Department of Public
12        Health for breast or cervical cancer screening.
13        "Medical assistance" under this paragraph 12 shall be
14    identical to the benefits provided under the State's
15    approved plan under Title XIX of the Social Security Act.
16    The Department must request federal approval of the
17    coverage under this paragraph 12 within 30 days after the
18    effective date of this amendatory Act of the 92nd General
19    Assembly.
20        In addition to the persons who are eligible for medical
21    assistance pursuant to subparagraphs (1) and (2) of this
22    paragraph 12, and to be paid from funds appropriated to the
23    Department for its medical programs, any uninsured person
24    as defined by the Department in rules residing in Illinois
25    who is younger than 65 years of age, who has been screened
26    for breast and cervical cancer in accordance with standards

 

 

10100SB1909sam004- 30 -LRB101 09278 CPF 59162 a

1    and procedures adopted by the Department of Public Health
2    for screening, and who is referred to the Department by the
3    Department of Public Health as being in need of treatment
4    for breast or cervical cancer is eligible for medical
5    assistance benefits that are consistent with the benefits
6    provided to those persons described in subparagraphs (1)
7    and (2). Medical assistance coverage for the persons who
8    are eligible under the preceding sentence is not dependent
9    on federal approval, but federal moneys may be used to pay
10    for services provided under that coverage upon federal
11    approval.
12        13. Subject to appropriation and to federal approval,
13    persons living with HIV/AIDS who are not otherwise eligible
14    under this Article and who qualify for services covered
15    under Section 5-5.04 as provided by the Illinois Department
16    by rule.
17        14. Subject to the availability of funds for this
18    purpose, the Department may provide coverage under this
19    Article to persons who reside in Illinois who are not
20    eligible under any of the preceding paragraphs and who meet
21    the income guidelines of paragraph 2(a) of this Section and
22    (i) have an application for asylum pending before the
23    federal Department of Homeland Security or on appeal before
24    a court of competent jurisdiction and are represented
25    either by counsel or by an advocate accredited by the
26    federal Department of Homeland Security and employed by a

 

 

10100SB1909sam004- 31 -LRB101 09278 CPF 59162 a

1    not-for-profit organization in regard to that application
2    or appeal, or (ii) are receiving services through a
3    federally funded torture treatment center. Medical
4    coverage under this paragraph 14 may be provided for up to
5    24 continuous months from the initial eligibility date so
6    long as an individual continues to satisfy the criteria of
7    this paragraph 14. If an individual has an appeal pending
8    regarding an application for asylum before the Department
9    of Homeland Security, eligibility under this paragraph 14
10    may be extended until a final decision is rendered on the
11    appeal. The Department may adopt rules governing the
12    implementation of this paragraph 14.
13        15. Family Care Eligibility.
14            (a) On and after July 1, 2012, a parent or other
15        caretaker relative who is 19 years of age or older when
16        countable income is at or below 133% of the federal
17        poverty level. A person may not spend down to become
18        eligible under this paragraph 15.
19            (b) Eligibility shall be reviewed annually.
20            (c) (Blank).
21            (d) (Blank).
22            (e) (Blank).
23            (f) (Blank).
24            (g) (Blank).
25            (h) (Blank).
26            (i) Following termination of an individual's

 

 

10100SB1909sam004- 32 -LRB101 09278 CPF 59162 a

1        coverage under this paragraph 15, the individual must
2        be determined eligible before the person can be
3        re-enrolled.
4        16. Subject to appropriation, uninsured persons who
5    are not otherwise eligible under this Section who have been
6    certified and referred by the Department of Public Health
7    as having been screened and found to need diagnostic
8    evaluation or treatment, or both diagnostic evaluation and
9    treatment, for prostate or testicular cancer. For the
10    purposes of this paragraph 16, uninsured persons are those
11    who do not have creditable coverage, as defined under the
12    Health Insurance Portability and Accountability Act, or
13    have otherwise exhausted any insurance benefits they may
14    have had, for prostate or testicular cancer diagnostic
15    evaluation or treatment, or both diagnostic evaluation and
16    treatment. To be eligible, a person must furnish a Social
17    Security number. A person's assets are exempt from
18    consideration in determining eligibility under this
19    paragraph 16. Such persons shall be eligible for medical
20    assistance under this paragraph 16 for so long as they need
21    treatment for the cancer. A person shall be considered to
22    need treatment if, in the opinion of the person's treating
23    physician, the person requires therapy directed toward
24    cure or palliation of prostate or testicular cancer,
25    including recurrent metastatic cancer that is a known or
26    presumed complication of prostate or testicular cancer and

 

 

10100SB1909sam004- 33 -LRB101 09278 CPF 59162 a

1    complications resulting from the treatment modalities
2    themselves. Persons who require only routine monitoring
3    services are not considered to need treatment. "Medical
4    assistance" under this paragraph 16 shall be identical to
5    the benefits provided under the State's approved plan under
6    Title XIX of the Social Security Act. Notwithstanding any
7    other provision of law, the Department (i) does not have a
8    claim against the estate of a deceased recipient of
9    services under this paragraph 16 and (ii) does not have a
10    lien against any homestead property or other legal or
11    equitable real property interest owned by a recipient of
12    services under this paragraph 16.
13        17. Persons who, pursuant to a waiver approved by the
14    Secretary of the U.S. Department of Health and Human
15    Services, are eligible for medical assistance under Title
16    XIX or XXI of the federal Social Security Act.
17    Notwithstanding any other provision of this Code and
18    consistent with the terms of the approved waiver, the
19    Illinois Department, may by rule:
20            (a) Limit the geographic areas in which the waiver
21        program operates.
22            (b) Determine the scope, quantity, duration, and
23        quality, and the rate and method of reimbursement, of
24        the medical services to be provided, which may differ
25        from those for other classes of persons eligible for
26        assistance under this Article.

 

 

10100SB1909sam004- 34 -LRB101 09278 CPF 59162 a

1            (c) Restrict the persons' freedom in choice of
2        providers.
3        18. Beginning January 1, 2014, persons aged 19 or
4    older, but younger than 65, who are not otherwise eligible
5    for medical assistance under this Section 5-2, who qualify
6    for medical assistance pursuant to 42 U.S.C.
7    1396a(a)(10)(A)(i)(VIII) and applicable federal
8    regulations, and who have income at or below 133% of the
9    federal poverty level plus 5% for the applicable family
10    size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
11    applicable federal regulations. Persons eligible for
12    medical assistance under this paragraph 18 shall receive
13    coverage for the Health Benefits Service Package as that
14    term is defined in subsection (m) of Section 5-1.1 of this
15    Code. If Illinois' federal medical assistance percentage
16    (FMAP) is reduced below 90% for persons eligible for
17    medical assistance under this paragraph 18, eligibility
18    under this paragraph 18 shall cease no later than the end
19    of the third month following the month in which the
20    reduction in FMAP takes effect.
21        19. Beginning January 1, 2014, as required under 42
22    U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
23    and younger than age 26 who are not otherwise eligible for
24    medical assistance under paragraphs (1) through (17) of
25    this Section who (i) were in foster care under the
26    responsibility of the State on the date of attaining age 18

 

 

10100SB1909sam004- 35 -LRB101 09278 CPF 59162 a

1    or on the date of attaining age 21 when a court has
2    continued wardship for good cause as provided in Section
3    2-31 of the Juvenile Court Act of 1987 and (ii) received
4    medical assistance under the Illinois Title XIX State Plan
5    or waiver of such plan while in foster care.
6        20. Beginning January 1, 2018, persons who are
7    foreign-born victims of human trafficking, torture, or
8    other serious crimes as defined in Section 2-19 of this
9    Code and their derivative family members if such persons:
10    (i) reside in Illinois; (ii) are not eligible under any of
11    the preceding paragraphs; (iii) meet the income guidelines
12    of subparagraph (a) of paragraph 2; and (iv) meet the
13    nonfinancial eligibility requirements of Sections 16-2,
14    16-3, and 16-5 of this Code. The Department may extend
15    medical assistance for persons who are foreign-born
16    victims of human trafficking, torture, or other serious
17    crimes whose medical assistance would be terminated
18    pursuant to subsection (b) of Section 16-5 if the
19    Department determines that the person, during the year of
20    initial eligibility (1) experienced a health crisis, (2)
21    has been unable, after reasonable attempts, to obtain
22    necessary information from a third party, or (3) has other
23    extenuating circumstances that prevented the person from
24    completing his or her application for status. The
25    Department may adopt any rules necessary to implement the
26    provisions of this paragraph.

 

 

10100SB1909sam004- 36 -LRB101 09278 CPF 59162 a

1    In implementing the provisions of Public Act 96-20, the
2Department is authorized to adopt only those rules necessary,
3including emergency rules. Nothing in Public Act 96-20 permits
4the Department to adopt rules or issue a decision that expands
5eligibility for the FamilyCare Program to a person whose income
6exceeds 185% of the Federal Poverty Level as determined from
7time to time by the U.S. Department of Health and Human
8Services, unless the Department is provided with express
9statutory authority.
10    The eligibility of any such person for medical assistance
11under this Article is not affected by the payment of any grant
12under the Senior Citizens and Persons with Disabilities
13Property Tax Relief Act or any distributions or items of income
14described under subparagraph (X) of paragraph (2) of subsection
15(a) of Section 203 of the Illinois Income Tax Act.
16    The Department shall by rule establish the amounts of
17assets to be disregarded in determining eligibility for medical
18assistance, which shall at a minimum equal the amounts to be
19disregarded under the Federal Supplemental Security Income
20Program. The amount of assets of a single person to be
21disregarded shall not be less than $2,000, and the amount of
22assets of a married couple to be disregarded shall not be less
23than $3,000.
24    To the extent permitted under federal law, any person found
25guilty of a second violation of Article VIIIA shall be
26ineligible for medical assistance under this Article, as

 

 

10100SB1909sam004- 37 -LRB101 09278 CPF 59162 a

1provided in Section 8A-8.
2    The eligibility of any person for medical assistance under
3this Article shall not be affected by the receipt by the person
4of donations or benefits from fundraisers held for the person
5in cases of serious illness, as long as neither the person nor
6members of the person's family have actual control over the
7donations or benefits or the disbursement of the donations or
8benefits.
9    Notwithstanding any other provision of this Code, if the
10United States Supreme Court holds Title II, Subtitle A, Section
112001(a) of Public Law 111-148 to be unconstitutional, or if a
12holding of Public Law 111-148 makes Medicaid eligibility
13allowed under Section 2001(a) inoperable, the State or a unit
14of local government shall be prohibited from enrolling
15individuals in the Medical Assistance Program as the result of
16federal approval of a State Medicaid waiver on or after the
17effective date of this amendatory Act of the 97th General
18Assembly, and any individuals enrolled in the Medical
19Assistance Program pursuant to eligibility permitted as a
20result of such a State Medicaid waiver shall become immediately
21ineligible.
22    Notwithstanding any other provision of this Code, if an Act
23of Congress that becomes a Public Law eliminates Section
242001(a) of Public Law 111-148, the State or a unit of local
25government shall be prohibited from enrolling individuals in
26the Medical Assistance Program as the result of federal

 

 

10100SB1909sam004- 38 -LRB101 09278 CPF 59162 a

1approval of a State Medicaid waiver on or after the effective
2date of this amendatory Act of the 97th General Assembly, and
3any individuals enrolled in the Medical Assistance Program
4pursuant to eligibility permitted as a result of such a State
5Medicaid waiver shall become immediately ineligible.
6    Effective October 1, 2013, the determination of
7eligibility of persons who qualify under paragraphs 5, 6, 8,
815, 17, and 18 of this Section shall comply with the
9requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
10regulations.
11    The Department of Healthcare and Family Services, the
12Department of Human Services, and the Illinois health insurance
13marketplace shall work cooperatively to assist persons who
14would otherwise lose health benefits as a result of changes
15made under this amendatory Act of the 98th General Assembly to
16transition to other health insurance coverage.
17(Source: P.A. 98-104, eff. 7-22-13; 98-463, eff. 8-16-13;
1899-143, eff. 7-27-15; 99-870, eff. 8-22-16.)
 
19    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
20    Sec. 5-5. Medical services. The Illinois Department, by
21rule, shall determine the quantity and quality of and the rate
22of reimbursement for the medical assistance for which payment
23will be authorized, and the medical services to be provided,
24which may include all or part of the following: (1) inpatient
25hospital services; (2) outpatient hospital services; (3) other

 

 

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1laboratory and X-ray services; (4) skilled nursing home
2services; (5) physicians' services whether furnished in the
3office, the patient's home, a hospital, a skilled nursing home,
4or elsewhere; (6) medical care, or any other type of remedial
5care furnished by licensed practitioners; (7) home health care
6services; (8) private duty nursing service; (9) clinic
7services; (10) dental services, including prevention and
8treatment of periodontal disease and dental caries disease for
9pregnant women, provided by an individual licensed to practice
10dentistry or dental surgery; for purposes of this item (10),
11"dental services" means diagnostic, preventive, or corrective
12procedures provided by or under the supervision of a dentist in
13the practice of his or her profession; (11) physical therapy
14and related services; (12) prescribed drugs, dentures, and
15prosthetic devices; and eyeglasses prescribed by a physician
16skilled in the diseases of the eye, or by an optometrist,
17whichever the person may select; (13) other diagnostic,
18screening, preventive, and rehabilitative services, including
19to ensure that the individual's need for intervention or
20treatment of mental disorders or substance use disorders or
21co-occurring mental health and substance use disorders is
22determined using a uniform screening, assessment, and
23evaluation process inclusive of criteria, for children and
24adults; for purposes of this item (13), a uniform screening,
25assessment, and evaluation process refers to a process that
26includes an appropriate evaluation and, as warranted, a

 

 

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1referral; "uniform" does not mean the use of a singular
2instrument, tool, or process that all must utilize; (14)
3transportation and such other expenses as may be necessary;
4(15) medical treatment of sexual assault survivors, as defined
5in Section 1a of the Sexual Assault Survivors Emergency
6Treatment Act, for injuries sustained as a result of the sexual
7assault, including examinations and laboratory tests to
8discover evidence which may be used in criminal proceedings
9arising from the sexual assault; (16) the diagnosis and
10treatment of sickle cell anemia; and (17) any other medical
11care, and any other type of remedial care recognized under the
12laws of this State. The term "any other type of remedial care"
13shall include nursing care and nursing home service for persons
14who rely on treatment by spiritual means alone through prayer
15for healing.
16    Notwithstanding any other provision of this Section, a
17comprehensive tobacco use cessation program that includes
18purchasing prescription drugs or prescription medical devices
19approved by the Food and Drug Administration shall be covered
20under the medical assistance program under this Article for
21persons who are otherwise eligible for assistance under this
22Article.
23    Notwithstanding any other provision of this Code,
24reproductive health care that is otherwise legal in Illinois
25shall be covered under the medical assistance program for
26persons who are otherwise eligible for medical assistance under

 

 

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1this Article.
2    Notwithstanding any other provision of this Code, the
3Illinois Department may not require, as a condition of payment
4for any laboratory test authorized under this Article, that a
5physician's handwritten signature appear on the laboratory
6test order form. The Illinois Department may, however, impose
7other appropriate requirements regarding laboratory test order
8documentation.
9    Upon receipt of federal approval of an amendment to the
10Illinois Title XIX State Plan for this purpose, the Department
11shall authorize the Chicago Public Schools (CPS) to procure a
12vendor or vendors to manufacture eyeglasses for individuals
13enrolled in a school within the CPS system. CPS shall ensure
14that its vendor or vendors are enrolled as providers in the
15medical assistance program and in any capitated Medicaid
16managed care entity (MCE) serving individuals enrolled in a
17school within the CPS system. Under any contract procured under
18this provision, the vendor or vendors must serve only
19individuals enrolled in a school within the CPS system. Claims
20for services provided by CPS's vendor or vendors to recipients
21of benefits in the medical assistance program under this Code,
22the Children's Health Insurance Program, or the Covering ALL
23KIDS Health Insurance Program shall be submitted to the
24Department or the MCE in which the individual is enrolled for
25payment and shall be reimbursed at the Department's or the
26MCE's established rates or rate methodologies for eyeglasses.

 

 

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1    On and after July 1, 2012, the Department of Healthcare and
2Family Services may provide the following services to persons
3eligible for assistance under this Article who are
4participating in education, training or employment programs
5operated by the Department of Human Services as successor to
6the Department of Public Aid:
7        (1) dental services provided by or under the
8    supervision of a dentist; and
9        (2) eyeglasses prescribed by a physician skilled in the
10    diseases of the eye, or by an optometrist, whichever the
11    person may select.
12    On and after July 1, 2018, the Department of Healthcare and
13Family Services shall provide dental services to any adult who
14is otherwise eligible for assistance under the medical
15assistance program. As used in this paragraph, "dental
16services" means diagnostic, preventative, restorative, or
17corrective procedures, including procedures and services for
18the prevention and treatment of periodontal disease and dental
19caries disease, provided by an individual who is licensed to
20practice dentistry or dental surgery or who is under the
21supervision of a dentist in the practice of his or her
22profession.
23    On and after July 1, 2018, targeted dental services, as set
24forth in Exhibit D of the Consent Decree entered by the United
25States District Court for the Northern District of Illinois,
26Eastern Division, in the matter of Memisovski v. Maram, Case

 

 

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1No. 92 C 1982, that are provided to adults under the medical
2assistance program shall be established at no less than the
3rates set forth in the "New Rate" column in Exhibit D of the
4Consent Decree for targeted dental services that are provided
5to persons under the age of 18 under the medical assistance
6program.
7    Notwithstanding any other provision of this Code and
8subject to federal approval, the Department may adopt rules to
9allow a dentist who is volunteering his or her service at no
10cost to render dental services through an enrolled
11not-for-profit health clinic without the dentist personally
12enrolling as a participating provider in the medical assistance
13program. A not-for-profit health clinic shall include a public
14health clinic or Federally Qualified Health Center or other
15enrolled provider, as determined by the Department, through
16which dental services covered under this Section are performed.
17The Department shall establish a process for payment of claims
18for reimbursement for covered dental services rendered under
19this provision.
20    The Illinois Department, by rule, may distinguish and
21classify the medical services to be provided only in accordance
22with the classes of persons designated in Section 5-2.
23    The Department of Healthcare and Family Services must
24provide coverage and reimbursement for amino acid-based
25elemental formulas, regardless of delivery method, for the
26diagnosis and treatment of (i) eosinophilic disorders and (ii)

 

 

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1short bowel syndrome when the prescribing physician has issued
2a written order stating that the amino acid-based elemental
3formula is medically necessary.
4    The Illinois Department shall authorize the provision of,
5and shall authorize payment for, screening by low-dose
6mammography for the presence of occult breast cancer for women
735 years of age or older who are eligible for medical
8assistance under this Article, as follows:
9        (A) A baseline mammogram for women 35 to 39 years of
10    age.
11        (B) An annual mammogram for women 40 years of age or
12    older.
13        (C) A mammogram at the age and intervals considered
14    medically necessary by the woman's health care provider for
15    women under 40 years of age and having a family history of
16    breast cancer, prior personal history of breast cancer,
17    positive genetic testing, or other risk factors.
18        (D) A comprehensive ultrasound screening and MRI of an
19    entire breast or breasts if a mammogram demonstrates
20    heterogeneous or dense breast tissue, when medically
21    necessary as determined by a physician licensed to practice
22    medicine in all of its branches.
23        (E) A screening MRI when medically necessary, as
24    determined by a physician licensed to practice medicine in
25    all of its branches.
26    All screenings shall include a physical breast exam,

 

 

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1instruction on self-examination and information regarding the
2frequency of self-examination and its value as a preventative
3tool. For purposes of this Section, "low-dose mammography"
4means the x-ray examination of the breast using equipment
5dedicated specifically for mammography, including the x-ray
6tube, filter, compression device, and image receptor, with an
7average radiation exposure delivery of less than one rad per
8breast for 2 views of an average size breast. The term also
9includes digital mammography and includes breast
10tomosynthesis. As used in this Section, the term "breast
11tomosynthesis" means a radiologic procedure that involves the
12acquisition of projection images over the stationary breast to
13produce cross-sectional digital three-dimensional images of
14the breast. If, at any time, the Secretary of the United States
15Department of Health and Human Services, or its successor
16agency, promulgates rules or regulations to be published in the
17Federal Register or publishes a comment in the Federal Register
18or issues an opinion, guidance, or other action that would
19require the State, pursuant to any provision of the Patient
20Protection and Affordable Care Act (Public Law 111-148),
21including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
22successor provision, to defray the cost of any coverage for
23breast tomosynthesis outlined in this paragraph, then the
24requirement that an insurer cover breast tomosynthesis is
25inoperative other than any such coverage authorized under
26Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and

 

 

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1the State shall not assume any obligation for the cost of
2coverage for breast tomosynthesis set forth in this paragraph.
3    On and after January 1, 2016, the Department shall ensure
4that all networks of care for adult clients of the Department
5include access to at least one breast imaging Center of Imaging
6Excellence as certified by the American College of Radiology.
7    On and after January 1, 2012, providers participating in a
8quality improvement program approved by the Department shall be
9reimbursed for screening and diagnostic mammography at the same
10rate as the Medicare program's rates, including the increased
11reimbursement for digital mammography.
12    The Department shall convene an expert panel including
13representatives of hospitals, free-standing mammography
14facilities, and doctors, including radiologists, to establish
15quality standards for mammography.
16    On and after January 1, 2017, providers participating in a
17breast cancer treatment quality improvement program approved
18by the Department shall be reimbursed for breast cancer
19treatment at a rate that is no lower than 95% of the Medicare
20program's rates for the data elements included in the breast
21cancer treatment quality program.
22    The Department shall convene an expert panel, including
23representatives of hospitals, free-standing breast cancer
24treatment centers, breast cancer quality organizations, and
25doctors, including breast surgeons, reconstructive breast
26surgeons, oncologists, and primary care providers to establish

 

 

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1quality standards for breast cancer treatment.
2    Subject to federal approval, the Department shall
3establish a rate methodology for mammography at federally
4qualified health centers and other encounter-rate clinics.
5These clinics or centers may also collaborate with other
6hospital-based mammography facilities. By January 1, 2016, the
7Department shall report to the General Assembly on the status
8of the provision set forth in this paragraph.
9    The Department shall establish a methodology to remind
10women who are age-appropriate for screening mammography, but
11who have not received a mammogram within the previous 18
12months, of the importance and benefit of screening mammography.
13The Department shall work with experts in breast cancer
14outreach and patient navigation to optimize these reminders and
15shall establish a methodology for evaluating their
16effectiveness and modifying the methodology based on the
17evaluation.
18    The Department shall establish a performance goal for
19primary care providers with respect to their female patients
20over age 40 receiving an annual mammogram. This performance
21goal shall be used to provide additional reimbursement in the
22form of a quality performance bonus to primary care providers
23who meet that goal.
24    The Department shall devise a means of case-managing or
25patient navigation for beneficiaries diagnosed with breast
26cancer. This program shall initially operate as a pilot program

 

 

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1in areas of the State with the highest incidence of mortality
2related to breast cancer. At least one pilot program site shall
3be in the metropolitan Chicago area and at least one site shall
4be outside the metropolitan Chicago area. On or after July 1,
52016, the pilot program shall be expanded to include one site
6in western Illinois, one site in southern Illinois, one site in
7central Illinois, and 4 sites within metropolitan Chicago. An
8evaluation of the pilot program shall be carried out measuring
9health outcomes and cost of care for those served by the pilot
10program compared to similarly situated patients who are not
11served by the pilot program.
12    The Department shall require all networks of care to
13develop a means either internally or by contract with experts
14in navigation and community outreach to navigate cancer
15patients to comprehensive care in a timely fashion. The
16Department shall require all networks of care to include access
17for patients diagnosed with cancer to at least one academic
18commission on cancer-accredited cancer program as an
19in-network covered benefit.
20    On or after July 1, 2019, women who are otherwise eligible
21for medical assistance under this Article shall receive
22coverage for doula services by a certified doula during their
23pregnancy and during the 12-month period beginning on the last
24day of their pregnancy. As used in this paragraph, "certified
25doula" means an individual who has received a certification to
26perform doula services from the International Childbirth

 

 

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1Education Association, the Doulas of North America, the
2Association of Labor Assistants and Childbirth Educators,
3BirthWorks, the Childbirth and Postpartum Professional
4Association, Childbirth International, the International
5Center for Traditional Childbearing, or Commonsense Childbirth
6Inc. As used in this paragraph, "doula services" means
7continuous personal, non-medical emotional and physical
8support throughout labor and birth, and intermittently during
9the prenatal and postpartum periods.
10    On or after July 1, 2019, women who are otherwise eligible
11for medical assistance under this Article shall receive
12coverage for perinatal depression screenings for the 12-month
13period beginning on the last day of their pregnancy. Medical
14assistance coverage under this paragraph shall be conditioned
15on the use of a screening instrument approved by the
16Department.
17    Any medical or health care provider shall immediately
18recommend, to any pregnant woman who is being provided prenatal
19services and is suspected of having a substance use disorder as
20defined in the Substance Use Disorder Act, referral to a local
21substance use disorder treatment program licensed by the
22Department of Human Services or to a licensed hospital which
23provides substance abuse treatment services. The Department of
24Healthcare and Family Services shall assure coverage for the
25cost of treatment of the drug abuse or addiction for pregnant
26recipients in accordance with the Illinois Medicaid Program in

 

 

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1conjunction with the Department of Human Services.
2    All medical providers providing medical assistance to
3pregnant women under this Code shall receive information from
4the Department on the availability of services under any
5program providing case management services for addicted women,
6including information on appropriate referrals for other
7social services that may be needed by addicted women in
8addition to treatment for addiction.
9    The Illinois Department, in cooperation with the
10Departments of Human Services (as successor to the Department
11of Alcoholism and Substance Abuse) and Public Health, through a
12public awareness campaign, may provide information concerning
13treatment for alcoholism and drug abuse and addiction, prenatal
14health care, and other pertinent programs directed at reducing
15the number of drug-affected infants born to recipients of
16medical assistance.
17    Neither the Department of Healthcare and Family Services
18nor the Department of Human Services shall sanction the
19recipient solely on the basis of her substance abuse.
20    The Illinois Department shall establish such regulations
21governing the dispensing of health services under this Article
22as it shall deem appropriate. The Department should seek the
23advice of formal professional advisory committees appointed by
24the Director of the Illinois Department for the purpose of
25providing regular advice on policy and administrative matters,
26information dissemination and educational activities for

 

 

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1medical and health care providers, and consistency in
2procedures to the Illinois Department.
3    The Illinois Department may develop and contract with
4Partnerships of medical providers to arrange medical services
5for persons eligible under Section 5-2 of this Code.
6Implementation of this Section may be by demonstration projects
7in certain geographic areas. The Partnership shall be
8represented by a sponsor organization. The Department, by rule,
9shall develop qualifications for sponsors of Partnerships.
10Nothing in this Section shall be construed to require that the
11sponsor organization be a medical organization.
12    The sponsor must negotiate formal written contracts with
13medical providers for physician services, inpatient and
14outpatient hospital care, home health services, treatment for
15alcoholism and substance abuse, and other services determined
16necessary by the Illinois Department by rule for delivery by
17Partnerships. Physician services must include prenatal and
18obstetrical care. The Illinois Department shall reimburse
19medical services delivered by Partnership providers to clients
20in target areas according to provisions of this Article and the
21Illinois Health Finance Reform Act, except that:
22        (1) Physicians participating in a Partnership and
23    providing certain services, which shall be determined by
24    the Illinois Department, to persons in areas covered by the
25    Partnership may receive an additional surcharge for such
26    services.

 

 

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

 

 

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1States Health Care Financing Administration to allow for the
2implementation of Partnerships under this Section.
3    The Illinois Department shall require health care
4providers to maintain records that document the medical care
5and services provided to recipients of Medical Assistance under
6this Article. Such records must be retained for a period of not
7less than 6 years from the date of service or as provided by
8applicable State law, whichever period is longer, except that
9if an audit is initiated within the required retention period
10then the records must be retained until the audit is completed
11and every exception is resolved. The Illinois Department shall
12require health care providers to make available, when
13authorized by the patient, in writing, the medical records in a
14timely fashion to other health care providers who are treating
15or serving persons eligible for Medical Assistance under this
16Article. All dispensers of medical services shall be required
17to maintain and retain business and professional records
18sufficient to fully and accurately document the nature, scope,
19details and receipt of the health care provided to persons
20eligible for medical assistance under this Code, in accordance
21with regulations promulgated by the Illinois Department. The
22rules and regulations shall require that proof of the receipt
23of prescription drugs, dentures, prosthetic devices and
24eyeglasses by eligible persons under this Section accompany
25each claim for reimbursement submitted by the dispenser of such
26medical services. No such claims for reimbursement shall be

 

 

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1approved for payment by the Illinois Department without such
2proof of receipt, unless the Illinois Department shall have put
3into effect and shall be operating a system of post-payment
4audit and review which shall, on a sampling basis, be deemed
5adequate by the Illinois Department to assure that such drugs,
6dentures, prosthetic devices and eyeglasses for which payment
7is being made are actually being received by eligible
8recipients. Within 90 days after September 16, 1984 (the
9effective date of Public Act 83-1439), the Illinois Department
10shall establish a current list of acquisition costs for all
11prosthetic devices and any other items recognized as medical
12equipment and supplies reimbursable under this Article and
13shall update such list on a quarterly basis, except that the
14acquisition costs of all prescription drugs shall be updated no
15less frequently than every 30 days as required by Section
165-5.12.
17    Notwithstanding any other law to the contrary, the Illinois
18Department shall, within 365 days after July 22, 2013 (the
19effective date of Public Act 98-104), establish procedures to
20permit skilled care facilities licensed under the Nursing Home
21Care Act to submit monthly billing claims for reimbursement
22purposes. Following development of these procedures, the
23Department shall, by July 1, 2016, test the viability of the
24new system and implement any necessary operational or
25structural changes to its information technology platforms in
26order to allow for the direct acceptance and payment of nursing

 

 

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1home claims.
2    Notwithstanding any other law to the contrary, the Illinois
3Department shall, within 365 days after August 15, 2014 (the
4effective date of Public Act 98-963), establish procedures to
5permit ID/DD facilities licensed under the ID/DD Community Care
6Act and MC/DD facilities licensed under the MC/DD Act to submit
7monthly billing claims for reimbursement purposes. Following
8development of these procedures, the Department shall have an
9additional 365 days to test the viability of the new system and
10to ensure that any necessary operational or structural changes
11to its information technology platforms are implemented.
12    The Illinois Department shall require all dispensers of
13medical services, other than an individual practitioner or
14group of practitioners, desiring to participate in the Medical
15Assistance program established under this Article to disclose
16all financial, beneficial, ownership, equity, surety or other
17interests in any and all firms, corporations, partnerships,
18associations, business enterprises, joint ventures, agencies,
19institutions or other legal entities providing any form of
20health care services in this State under this Article.
21    The Illinois Department may require that all dispensers of
22medical services desiring to participate in the medical
23assistance program established under this Article disclose,
24under such terms and conditions as the Illinois Department may
25by rule establish, all inquiries from clients and attorneys
26regarding medical bills paid by the Illinois Department, which

 

 

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1inquiries could indicate potential existence of claims or liens
2for the Illinois Department.
3    Enrollment of a vendor shall be subject to a provisional
4period and shall be conditional for one year. During the period
5of conditional enrollment, the Department may terminate the
6vendor's eligibility to participate in, or may disenroll the
7vendor from, the medical assistance program without cause.
8Unless otherwise specified, such termination of eligibility or
9disenrollment is not subject to the Department's hearing
10process. However, a disenrolled vendor may reapply without
11penalty.
12    The Department has the discretion to limit the conditional
13enrollment period for vendors based upon category of risk of
14the vendor.
15    Prior to enrollment and during the conditional enrollment
16period in the medical assistance program, all vendors shall be
17subject to enhanced oversight, screening, and review based on
18the risk of fraud, waste, and abuse that is posed by the
19category of risk of the vendor. The Illinois Department shall
20establish the procedures for oversight, screening, and review,
21which may include, but need not be limited to: criminal and
22financial background checks; fingerprinting; license,
23certification, and authorization verifications; unscheduled or
24unannounced site visits; database checks; prepayment audit
25reviews; audits; payment caps; payment suspensions; and other
26screening as required by federal or State law.

 

 

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1    The Department shall define or specify the following: (i)
2by provider notice, the "category of risk of the vendor" for
3each type of vendor, which shall take into account the level of
4screening applicable to a particular category of vendor under
5federal law and regulations; (ii) by rule or provider notice,
6the maximum length of the conditional enrollment period for
7each category of risk of the vendor; and (iii) by rule, the
8hearing rights, if any, afforded to a vendor in each category
9of risk of the vendor that is terminated or disenrolled during
10the conditional enrollment period.
11    To be eligible for payment consideration, a vendor's
12payment claim or bill, either as an initial claim or as a
13resubmitted claim following prior rejection, must be received
14by the Illinois Department, or its fiscal intermediary, no
15later than 180 days after the latest date on the claim on which
16medical goods or services were provided, with the following
17exceptions:
18        (1) In the case of a provider whose enrollment is in
19    process by the Illinois Department, the 180-day period
20    shall not begin until the date on the written notice from
21    the Illinois Department that the provider enrollment is
22    complete.
23        (2) In the case of errors attributable to the Illinois
24    Department or any of its claims processing intermediaries
25    which result in an inability to receive, process, or
26    adjudicate a claim, the 180-day period shall not begin

 

 

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1    until the provider has been notified of the error.
2        (3) In the case of a provider for whom the Illinois
3    Department initiates the monthly billing process.
4        (4) In the case of a provider operated by a unit of
5    local government with a population exceeding 3,000,000
6    when local government funds finance federal participation
7    for claims payments.
8    For claims for services rendered during a period for which
9a recipient received retroactive eligibility, claims must be
10filed within 180 days after the Department determines the
11applicant is eligible. For claims for which the Illinois
12Department is not the primary payer, claims must be submitted
13to the Illinois Department within 180 days after the final
14adjudication by the primary payer.
15    In the case of long term care facilities, within 45
16calendar days of receipt by the facility of required
17prescreening information, new admissions with associated
18admission documents shall be submitted through the Medical
19Electronic Data Interchange (MEDI) or the Recipient
20Eligibility Verification (REV) System or shall be submitted
21directly to the Department of Human Services using required
22admission forms. Effective September 1, 2014, admission
23documents, including all prescreening information, must be
24submitted through MEDI or REV. Confirmation numbers assigned to
25an accepted transaction shall be retained by a facility to
26verify timely submittal. Once an admission transaction has been

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1of the recipient or enrollee. Nothing in this paragraph shall
2be construed to limit recipient or enrollee choice to obtain
3new durable medical equipment or place any additional prior
4authorization conditions on enrollees of managed care
5organizations.
6    The Department shall execute, relative to the nursing home
7prescreening project, written inter-agency agreements with the
8Department of Human Services and the Department on Aging, to
9effect the following: (i) intake procedures and common
10eligibility criteria for those persons who are receiving
11non-institutional services; and (ii) the establishment and
12development of non-institutional services in areas of the State
13where they are not currently available or are undeveloped; and
14(iii) notwithstanding any other provision of law, subject to
15federal approval, on and after July 1, 2012, an increase in the
16determination of need (DON) scores from 29 to 37 for applicants
17for institutional and home and community-based long term care;
18if and only if federal approval is not granted, the Department
19may, in conjunction with other affected agencies, implement
20utilization controls or changes in benefit packages to
21effectuate a similar savings amount for this population; and
22(iv) no later than July 1, 2013, minimum level of care
23eligibility criteria for institutional and home and
24community-based long term care; and (v) no later than October
251, 2013, establish procedures to permit long term care
26providers access to eligibility scores for individuals with an

 

 

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1admission date who are seeking or receiving services from the
2long term care provider. In order to select the minimum level
3of care eligibility criteria, the Governor shall establish a
4workgroup that includes affected agency representatives and
5stakeholders representing the institutional and home and
6community-based long term care interests. This Section shall
7not restrict the Department from implementing lower level of
8care eligibility criteria for community-based services in
9circumstances where federal approval has been granted.
10    The Illinois Department shall develop and operate, in
11cooperation with other State Departments and agencies and in
12compliance with applicable federal laws and regulations,
13appropriate and effective systems of health care evaluation and
14programs for monitoring of utilization of health care services
15and facilities, as it affects persons eligible for medical
16assistance under this Code.
17    The Illinois Department shall report annually to the
18General Assembly, no later than the second Friday in April of
191979 and each year thereafter, in regard to:
20        (a) actual statistics and trends in utilization of
21    medical services by public aid recipients;
22        (b) actual statistics and trends in the provision of
23    the various medical services by medical vendors;
24        (c) current rate structures and proposed changes in
25    those rate structures for the various medical vendors; and
26        (d) efforts at utilization review and control by the

 

 

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1    Illinois Department.
2    The period covered by each report shall be the 3 years
3ending on the June 30 prior to the report. The report shall
4include suggested legislation for consideration by the General
5Assembly. The requirement for reporting to the General Assembly
6shall be satisfied by filing copies of the report as required
7by Section 3.1 of the General Assembly Organization Act, and
8filing such additional copies with the State Government Report
9Distribution Center for the General Assembly as is required
10under paragraph (t) of Section 7 of the State Library Act.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17    On and after July 1, 2012, the Department shall reduce any
18rate of reimbursement for services or other payments or alter
19any methodologies authorized by this Code to reduce any rate of
20reimbursement for services or other payments in accordance with
21Section 5-5e.
22    Because kidney transplantation can be an appropriate,
23cost-effective alternative to renal dialysis when medically
24necessary and notwithstanding the provisions of Section 1-11 of
25this Code, beginning October 1, 2014, the Department shall
26cover kidney transplantation for noncitizens with end-stage

 

 

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

 

 

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1shall be covered under the medical assistance program for
2persons who are otherwise eligible for medical assistance under
3this Article. As used in this Section, "opioid antagonist"
4means a drug that binds to opioid receptors and blocks or
5inhibits the effect of opioids acting on those receptors,
6including, but not limited to, naloxone hydrochloride or any
7other similarly acting drug approved by the U.S. Food and Drug
8Administration.
9    Upon federal approval, the Department shall provide
10coverage and reimbursement for all drugs that are approved for
11marketing by the federal Food and Drug Administration and that
12are recommended by the federal Public Health Service or the
13United States Centers for Disease Control and Prevention for
14pre-exposure prophylaxis and related pre-exposure prophylaxis
15services, including, but not limited to, HIV and sexually
16transmitted infection screening, treatment for sexually
17transmitted infections, medical monitoring, assorted labs, and
18counseling to reduce the likelihood of HIV infection among
19individuals who are not infected with HIV but who are at high
20risk of HIV infection.
21    A federally qualified health center, as defined in Section
221905(l)(2)(B) of the federal Social Security Act, shall be
23reimbursed by the Department in accordance with the federally
24qualified health center's encounter rate for services provided
25to medical assistance recipients that are performed by a dental
26hygienist, as defined under the Illinois Dental Practice Act,

 

 

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1working under the general supervision of a dentist and employed
2by a federally qualified health center.
3    Notwithstanding any other provision of this Code, the
4Illinois Department shall authorize licensed dietitian
5nutritionists and certified diabetes educators to counsel
6senior diabetes patients in the senior diabetes patients' homes
7to remove the hurdle of transportation for senior diabetes
8patients to receive treatment.
9    The Department shall seek approval of a State Plan
10amendment to expand coverage for family planning services to
11women whose income is at or below 200% of the federal poverty
12level.
13(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1499-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
15the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
1699-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
177-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
18eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
19100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
201-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
21100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
2212-10-18.)
 
23    (305 ILCS 5/5-5.24)
24    Sec. 5-5.24. Prenatal and perinatal care. The Department of
25Healthcare and Family Services may provide reimbursement under

 

 

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1this Article for all prenatal and perinatal health care
2services that are provided for the purpose of preventing
3low-birthweight infants, reducing the need for neonatal
4intensive care hospital services, and promoting perinatal and
5maternal health. These services may include comprehensive risk
6assessments for pregnant women, women with infants, and
7infants, lactation counseling, nutrition counseling,
8childbirth support, psychosocial counseling, treatment and
9prevention of periodontal disease, language translation, nurse
10home visitation, and other support services that have been
11proven to improve birth and maternal health outcomes. The
12Department shall maximize the use of preventive prenatal and
13perinatal health care services consistent with federal
14statutes, rules, and regulations. The Department of Public Aid
15(now Department of Healthcare and Family Services) shall
16develop a plan for prenatal and perinatal preventive health
17care and shall present the plan to the General Assembly by
18January 1, 2004. On or before January 1, 2006 and every 2 years
19thereafter, the Department shall report to the General Assembly
20concerning the effectiveness of prenatal and perinatal health
21care services reimbursed under this Section in preventing
22low-birthweight infants and reducing the need for neonatal
23intensive care hospital services. Each such report shall
24include an evaluation of how the ratio of expenditures for
25treating low-birthweight infants compared with the investment
26in promoting healthy births and infants in local community

 

 

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1areas throughout Illinois relates to healthy infant
2development in those areas.
3    On and after July 1, 2012, the Department shall reduce any
4rate of reimbursement for services or other payments or alter
5any methodologies authorized by this Code to reduce any rate of
6reimbursement for services or other payments in accordance with
7Section 5-5e.
8(Source: P.A. 97-689, eff. 6-14-12.)
 
9    Section 55. The Developmental Disability Prevention Act is
10amended by adding Section 11.2 as follows:
 
11    (410 ILCS 250/11.2 new)
12    Sec. 11.2. Birthing facilities; maternal care
13designations.
14    (a) In this Section, "birthing facility" means: (1) a
15hospital, as defined in the Hospital Licensing Act, with more
16than one licensed obstetric bed or a neonatal intensive care
17unit; (2) a hospital operated by a State university; or (3) a
18birth center, as defined in the Alternative Health Care
19Delivery Act.
20    (b) Every birthing facility shall, at a minimum, have an
21obstetric hemorrhage protocol and conduct a drill or simulation
22of the protocol. Every contracted provider who may encounter a
23pregnant woman shall participate in the drill or simulation on
24a regular basis. The Department shall adopt rules to implement

 

 

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1this subsection.
2    (c) After holding multiple public hearings with
3representatives from diverse geographical regions and
4professional backgrounds and seeking broad public and
5stakeholder input, the Department shall establish criteria for
6levels of maternal care designations for birthing facilities.
7All hearings shall be open to the public and held at specific
8times and places that are convenient and available to the
9public. No hearing shall be held on a legal holiday. Public
10notice of hearings shall state the dates, times, and places of
11the hearings. Notice of hearings shall be posted on the
12Department's website and in the Department's main office, and
13minutes from the hearings shall be recorded. The levels of
14maternal care designations developed under this Section shall
15be based upon:
16        (1) the most current published version of the "Levels
17    of Maternal Care" developed by the American Congress of
18    Obstetricians and Gynecologists and the Society for
19    Maternal-Fetal Medicine; and
20        (2) necessary variance when considering the geographic
21    and varied needs of citizens of this State.
22    (d) Nothing in this Section shall be construed in any way
23to modify or expand the licensure of any health care
24professional.
25    (e) Nothing in this Section shall be construed in any way
26to require a patient to be transferred to a different facility.

 

 

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1    (f) The Department shall adopt rules to implement the
2provisions of this Section no later than June 1, 2021. These
3rules shall be limited to those necessary for the establishment
4of levels of maternal care designations for birthing facilities
5under subsection (c) of this Section.
 
6    Section 95. No acceleration or delay. Where this Act makes
7changes in a statute that is represented in this Act by text
8that is not yet or no longer in effect (for example, a Section
9represented by multiple versions), the use of that text does
10not accelerate or delay the taking effect of (i) the changes
11made by this Act or (ii) provisions derived from any other
12Public Act.
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.".