305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-16.7)

(Text of Section before amendment by P.A. 103-720)

Sec. 5-16.7. Post-parturition care. The medical assistance program shall provide the post-parturition care benefits required to be covered by a policy of accident and health insurance under Section 356s of the Illinois Insurance Code.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(Source: P.A. 97-689, eff. 6-14-12.)

(Text of Section after amendment by P.A. 103-720)

Sec. 5-16.7. Post-parturition care. The medical assistance program shall provide the post-parturition care benefits required to be covered by a policy of accident and health insurance under Section 356s of the Illinois Insurance Code.

(Source: P.A. 103-720, eff. 1-1-26.)

(305 ILCS 5/5-16.7a)

Sec. 5-16.7a. Reimbursement for epidural anesthesia services. In addition to other procedures authorized by the Department under this Code, the Department shall provide reimbursement to medical providers for epidural anesthesia services when ordered by the attending practitioner at the time of delivery.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(Source: P.A. 97-689, eff. 6-14-12.)

(305 ILCS 5/5-16.8)

(Text of Section from P.A. 102-1117)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)

(Text of Section from P.A. 103-84, 103-91, and 103-420)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and 356z.61 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24.)

(305 ILCS 5/5-16.8a)

Sec. 5-16.8a. Rules concerning continuous glucose monitor coverage. The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules shall, at a minimum, provide that:

(1) the ordering provider must be a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician; the ordering provider is not required to obtain continuing medical education in order to prescribe a continuous glucose monitor;

(2) continuous glucose monitors are not required to have an alarm when glucose levels are outside the pre-determined range; the capacity to generate predictive alerts in case of impending hypoglycemia; or the ability to transmit real-time glucose values and alerts to the patient and designated other persons;

(3) the beneficiary is not required to need intensive insulin therapy;

(4) the beneficiary is not required to have a recent history of emergency room visits or hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis;

(5) if the beneficiary has gestational diabetes, the beneficiary is not required to have suboptimal glycemic control that is likely to harm the beneficiary or the fetus;

(6) if a beneficiary has diabetes mellitus and the beneficiary does not meet the coverage requirements or if the beneficiary is in a population in which continuous glucose monitor usage has not been well-studied, requests shall be reviewed, on a case-by-case basis, for medical necessity and approved if appropriate; and

(7) prior authorization is required for a prescription of a continuous glucose monitor; once a continuous glucose monitor is prescribed, the prior authorization shall be approved for a 12-month period.

(Source: P.A. 103-639, eff. 7-1-24.)

(305 ILCS 5/5-16.9)

Sec. 5-16.9. Access to obstetrical and gynecological care. The medical assistance program is subject to the provisions of Section 356r of the Illinois Insurance Code. The Illinois Department shall adopt rules to implement the requirements of Section 356r of the Illinois Insurance Code in the medical assistance program including managed care components.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(Source: P.A. 103-718, eff. 7-19-24.)

(305 ILCS 5/5-16.10)

Sec. 5-16.10. Managed care entities; marketing. A managed health care entity providing services under this Article V may not engage in door-to-door marketing activities or marketing activities at an office of the Illinois Department or a county department in order to enroll recipients in the entity's health care delivery system. The Department shall adopt rules defining "marketing activities" prohibited by this Section.

Before a managed health care entity providing services under this Article V may market its health care delivery system to recipients, the Illinois Department must approve a marketing plan submitted by the entity to the Illinois Department. The Illinois Department shall adopt guidelines for approving marketing plans submitted by managed health care entities under this Section. Besides prohibiting door-to-door marketing activities and marketing activities at public aid offices, the guidelines shall include at least the following:

(1) A managed health care entity may not offer or provide any gift, favor, or other inducement in marketing its health care delivery system to integrated health care program enrollees. A managed health care entity may provide health care related items that are of nominal value and pre-approved by the Department to prospective enrollees. A managed health care entity may also provide to enrollees health care related items that have been pre-approved by the Department as an incentive to manage their health care appropriately.

(2) All persons employed or otherwise engaged by a managed health care entity to market the entity's health care delivery system to recipients or to supervise that marketing shall register with the Illinois Department.

The Inspector General appointed under Section 12-13.1 may conduct investigations to determine whether the marketing practices of managed health care entities providing services under this Article V comply with the guidelines.

(Source: P.A. 90-538, eff. 12-1-97.)

(305 ILCS 5/5-16.11)

Sec. 5-16.11. Uniform standards applied to managed care entities. Any managed care entity providing services under this Code shall use a pharmacy formulary that is no more restrictive than the Illinois Department's pharmaceutical program.

(Source: P.A. 92-370, eff. 8-15-01.)

(305 ILCS 5/5-16.12)

(Text of Section before amendment by P.A. 103-650)

Sec. 5-16.12. Managed Care Reform and Patient Rights Act. The medical assistance program and other programs administered by the Department are subject to the provisions of the Managed Care Reform and Patient Rights Act. The Department may adopt rules to implement those provisions. These rules shall require compliance with that Act in the medical assistance managed care programs and other programs administered by the Department. The medical assistance fee-for-service program is not subject to the provisions of the Managed Care Reform and Patient Rights Act.

Nothing in the Managed Care Reform and Patient Rights Act shall be construed to mean that the Department is a health care plan as defined in that Act simply because the Department enters into contractual relationships with health care plans.

(Source: P.A. 91-617, eff. 1-1-00.)

(Text of Section after amendment by P.A. 103-650)

Sec. 5-16.12. Managed Care Reform and Patient Rights Act. The medical assistance program and other programs administered by the Department are subject to the provisions of the Managed Care Reform and Patient Rights Act. The Department may adopt rules to implement those provisions. These rules shall require compliance with that Act in the medical assistance managed care programs and other programs administered by the Department. The medical assistance fee-for-service program is not subject to the provisions of the Managed Care Reform and Patient Rights Act, except for Sections 85 and 87 of the Managed Care Reform and Patient Rights Act and for any definition in Section 10 of the Managed Care Reform and Patient Rights Act that applies to Sections 85 and 87 of the Managed Care Reform and Patient Rights Act.

Nothing in the Managed Care Reform and Patient Rights Act shall be construed to mean that the Department is a health care plan as defined in that Act simply because the Department enters into contractual relationships with health care plans; provided that this clause shall not defeat the applicability of Sections 10, 85, and 87 of the Managed Care Reform and Patient Rights Act to the fee-for-service program.

(Source: P.A. 103-650, eff. 1-1-25.)

(305 ILCS 5/5-16.13)

Sec. 5-16.13. (Repealed).

(Source: P.A. 93-674, eff. 6-10-04. Repealed internally, eff. 12-31-04.)

(305 ILCS 5/5-17) (from Ch. 23, par. 5-17)

Sec. 5-17. Programs to improve access to hospital care.

(a) (1) The General Assembly finds:

(A) That while hospitals have traditionally provided charitable care to indigent patients, this burden is not equally borne by all hospitals operating in this State. Some hospitals continue to provide significant amounts of care to low-income persons while others provide very little such care; and

(B) That access to hospital care in this State by the indigent citizens of Illinois would be seriously impaired by the closing of hospitals that provide significant amounts of care to low-income persons.

(2) To help expand the availability of hospital care for all citizens of this State, it is the policy of the State to implement programs that more equitably distribute the burden of providing hospital care to Illinois' low-income population and that improve access to health care in Illinois.

(3) The Illinois Department may develop and implement a program that lessens the burden of providing hospital care to Illinois' low-income population, taking into account the costs that must be incurred by hospitals providing significant amounts of care to low-income persons, and may develop adjustments to increase rates to improve access to health care in Illinois. The Illinois Department shall prescribe by rule the criteria, standards and procedures for effecting such adjustments in the rates of hospital payments for services provided to eligible low-income persons (under Articles V, VI and VII of this Code) under this Article.

(b) The Illinois Department shall require hospitals certified to participate in the federal Medicaid program to:

(1) provide equal access to available services to low-income persons who are eligible for assistance under Articles V, VI and VII of this Code;

(2) provide data and reports on the provision of uncompensated care.

(c) From the effective date of this amendatory Act of 1992 until July 1, 1992, nothing in this Section 5-17 shall be construed as creating a private right of action on behalf of any individual.

(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(Source: P.A. 97-689, eff. 6-14-12.)

(305 ILCS 5/5-18) (from Ch. 23, par. 5-18)

Sec. 5-18. (Repealed).

(Source: P.A. 87-895. Repealed by P.A. 92-275, eff. 8-7-01.)