305 ILCS 5/5-47

(305 ILCS 5/5-47)

(Text of Section from P.A. 103-102)

Sec. 5-47. Medicaid reimbursement rates; substance use disorder treatment providers and facilities.

(a) Beginning on January 1, 2024, subject to federal approval, the Department of Healthcare and Family Services, in conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, shall provide a 30% increase in reimbursement rates for all Medicaid-covered ASAM Level 3 residential/inpatient substance use disorder treatment services.

No existing or future reimbursement rates or add-ons shall be reduced or changed to address this proposed rate increase. No later than 3 months after the effective date of this amendatory Act of the 103rd General Assembly, the Department of Healthcare and Family Services shall submit any necessary application to the federal Centers for Medicare and Medicaid Services to implement the requirements of this Section.

(b) Parity in community-based behavioral health rates; implementation plan for cost reporting. For the purpose of understanding behavioral health services cost structures and their impact on the Medical Assistance Program, the Department of Healthcare and Family Services shall engage stakeholders to develop a plan for the regular collection of cost reporting for all entity-based substance use disorder providers. Data shall be used to inform on the effectiveness and efficiency of Illinois Medicaid rates. The Department and stakeholders shall develop a plan by April 1, 2024. The Department shall engage stakeholders on implementation of the plan. The plan, at minimum, shall consider all of the following:

(1) Alignment with certified community behavioral health clinic requirements, standards, policies, and procedures.

(2) Inclusion of prospective costs to measure what is needed to increase services and capacity.

(3) Consideration of differences in collection and policies based on the size of providers.

(4) Consideration of additional administrative time and costs.

(5) Goals, purposes, and usage of data collected from cost reports.

(6) Inclusion of qualitative data in addition to quantitative data.

(7) Technical assistance for providers for completing cost reports including initial training by the Department for providers.

(8) Implementation of a timeline which allows an initial grace period for providers to adjust internal procedures and data collection.

Details from collected cost reports shall be made publicly available on the Department's website and costs shall be used to ensure the effectiveness and efficiency of Illinois Medicaid rates.

(c) Reporting; access to substance use disorder treatment services and recovery supports. By no later than April 1, 2024, the Department of Healthcare and Family Services, with input from the Department of Human Services' Division of Substance Use Prevention and Recovery, shall submit a report to the General Assembly regarding access to treatment services and recovery supports for persons diagnosed with a substance use disorder. The report shall include, but is not limited to, the following information:

(1) The number of providers enrolled in the Illinois Medical Assistance Program certified to provide substance use disorder treatment services, aggregated by ASAM level of care, and recovery supports.

(2) The number of Medicaid customers in Illinois with a diagnosed substance use disorder receiving substance use disorder treatment, aggregated by provider type and ASAM level of care.

(3) A comparison of Illinois' substance use disorder licensure and certification requirements with those of comparable state Medicaid programs.

(4) Recommendations for and an analysis of the impact of aligning reimbursement rates for outpatient substance use disorder treatment services with reimbursement rates for community-based mental health treatment services.

(5) Recommendations for expanding substance use disorder treatment to other qualified provider entities and licensed professionals of the healing arts. The recommendations shall include an analysis of the opportunities to maximize the flexibilities permitted by the federal Centers for Medicare and Medicaid Services for expanding access to the number and types of qualified substance use disorder providers.

(Source: P.A. 103-102, eff. 6-16-23.)

(Text of Section from P.A. 103-243)

Sec. 5-47. Coverage for mental health and substance use disorder telehealth services.

(a) As used in this Section:

"Behavioral health care professional" has the meaning given to "health care professional" in Section 5 of the Telehealth Act, but only with respect to professionals licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services engaged in the delivery of mental health or substance use disorder treatment or services.

"Behavioral health facility" means a community mental health center, a behavioral health clinic, a substance use disorder treatment program, or a facility or provider licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services.

"Behavioral telehealth services" has the meaning given to the term "telehealth services" in Section 5 of the Telehealth Act, but limited solely to mental health and substance use disorder treatment or services to a patient, regardless of patient location.

"Distant site" has the meaning given to that term in Section 5 of the Telehealth Act.

"Originating site" has the meaning given to that term in Section 5 of the Telehealth Act.

(b) The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.

(c) To ensure behavioral telehealth services are equitably provided, coverage required under this Section shall comply with all of the following:

(1) The Department and any managed care plans under contract with the Department for the medical assistance program shall not:

(A) require that in-person contact occur between a behavioral health care professional and a patient before the provision of a behavioral telehealth service;

(B) require patients, behavioral health care professionals, or behavioral health facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of behavioral telehealth services;

(C) require the use of behavioral telehealth services when the behavioral health care professional has determined that it is not appropriate;

(D) require the use of behavioral telehealth services when a patient chooses an in-person consultation;

(E) require a behavioral health care professional to be physically present in the same room as the patient at the originating site, unless deemed medically necessary by the behavioral health care professional providing the behavioral telehealth service;

(F) create geographic or facility restrictions or requirements for behavioral telehealth services;

(G) require behavioral health care professionals or behavioral health facilities to offer or provide behavioral telehealth services;

(H) require patients to use behavioral telehealth services or require patients to use a separate panel of behavioral health care professionals or behavioral health facilities to receive behavioral telehealth services; or

(I) impose upon behavioral telehealth services utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same behavioral health care service when rendered in-person, except that procedure code modifiers may be required to document behavioral telehealth.

(2) Any cost sharing applicable to services provided through behavioral telehealth shall not exceed the cost sharing required by the medical assistance program for the same services provided through in-person consultation.

(3) The Department and any managed care plans under contract with the Department for the medical assistance program shall notify behavioral health care professionals and behavioral health facilities of any instructions necessary to facilitate billing for behavioral telehealth services.

(d) For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.

(e) Behavioral health care professionals and behavioral health facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a behavioral telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, 42 CFR Part 2, and the Mental Health and Developmental Disabilities Confidentiality Act.

(f) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from providing benefits for other telehealth services.

(g) There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.

(h) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from establishing limits on the use of telehealth for a particular behavioral health service when the limits are consistent with generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care.

(i) The Department may adopt rules to implement the provisions of this Section.

(Source: P.A. 103-243, eff. 1-1-24.)

(Text of Section from P.A. 103-325)

Sec. 5-47. Proton beam therapy; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for proton beam therapy. As used in this Section, "proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells. "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.

(Source: P.A. 103-325, eff. 1-1-24.)