305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-30.2)

Sec. 5-30.2. Monthly reports; managed care enrollment.

(a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a Care Coordination Entity (CCE) contracted by the Department.

(b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition, as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department. As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department:

(1) Total enrollment.

(2) The number of persons enrolled in the medical assistance program under items 18 and 19 of Section 5-2.

(3) The number of children enrolled.

(4) The number of parents and caretakers of minor children enrolled.

(5) The number of women enrolled on the basis of pregnancy.

(6) The number of seniors enrolled.

(7) The number of persons enrolled on the basis of disability.

(c) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section.

(d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year.

(e) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages.

(f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system.

(Source: P.A. 99-86, eff. 7-21-15.)

(305 ILCS 5/5-30.3)

Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care.

(a) Definitions. As used in this Section:

"Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities.

"Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures.

"Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format.

"Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan.

"Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers.

"Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals.

"Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services.

"Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated.

"Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code.

(b) Provider directory transparency.

(1) Each Medicaid Managed Care Entity shall:

(A) Make available on the entity's website a provider directory in a machine readable file and format.

(B) Make provider directories publicly accessible without the necessity of providing a password, a username, or personally identifiable information.

(C) Comply with all federal and State statutes and regulations, including 42 CFR 438.10, pertaining to provider directories within Medicaid Managed Care.

(D) Request, at least annually, provider office hours for each of the following provider types:

(i) Health care professionals, including dental and vision providers.

(ii) Hospitals.

(iii) Facilities, other than hospitals.

(iv) Pharmacies, other than hospitals.

(v) Durable medical equipment suppliers, other than hospitals.

Medicaid Managed Care Entities shall publish the provider office hours in the provider directory upon receipt.

(E) Confirm with the Medicaid Managed Care Entity's contracted providers who have not submitted claims within the past 6 months that the contracted providers intend to remain in the network and correct any incorrect provider directory information as necessary.

(F) Ensure that in situations in which a Medicaid Managed Care Entity Plan enrollee receives covered services from a non-participating provider due to a material misrepresentation in a Medicaid Managed Care Entity's online electronic provider directory, the Medicaid Managed Care Entity Plan enrollee shall not be held responsible for any costs resulting from that material misrepresentation.

(G) Conspicuously display an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the provider directory. If the Medicaid Managed Care Entity receives a report from any person who specifically identifies provider directory information as inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic directory.

(2) The Department shall:

(A) Regularly monitor Medicaid Managed Care Entities to ensure that they are compliant with the requirements under paragraph (1) of subsection (b).

(B) Require that the client enrollment services broker use the Medicaid provider number for all providers with a Medicaid Provider number to populate the provider information in the integrated provider directory.

(C) Ensure that each Medicaid Managed Care Entity shall, at minimum, make the information in subparagraph (D) of paragraph (1) of subsection (b) available to the client enrollment services broker.

(D) Ensure that the client enrollment services broker shall, at minimum, have the information in subparagraph (D) of paragraph (1) of subsection (b) available and searchable through the integrated provider directory on its website as soon as possible but no later than January 1, 2017.

(E) Require the client enrollment services broker to conspicuously display near the integrated provider directory an email address and a toll-free telephone number provided by the Department to which any individual may report inaccuracies in the integrated provider directory. If the Department receives a report that identifies an inaccuracy in the integrated provider directory, the Department shall provide the information about the reported inaccuracy to the appropriate Medicaid Managed Care Entity within 3 business days after the reported inaccuracy is received.

(c) Formulary transparency.

(1) Medicaid Managed Care Entities shall publish on their respective websites a formulary for each Medicaid Managed Care Entity Plan offered and make the formularies easily understandable and publicly accessible without the necessity of providing a password, a username, or personally identifiable information.

(2) Medicaid Managed Care Entities shall provide printed formularies upon request.

(3) Electronic and print formularies shall display:

(A) the medications covered (both generic and name brand);

(B) if the medication is preferred or not preferred, and what each term means;

(C) what tier each medication is in and the meaning of each tier;

(D) any utilization controls including, but not limited to, step therapy, prior approval, dosage limits, gender or age restrictions, quantity limits, or other policies that affect access to medications;

(E) any required cost-sharing;

(F) a glossary of key terms and explanation of utilization controls and cost-sharing requirements;

(G) a key or legend for all utilization controls visible on every page in which specific medication coverage information is displayed; and

(H) directions explaining the process or processes a consumer may follow to obtain more information if a medication the consumer requires is not covered or listed in the formulary.

(4) Each Medicaid Managed Care Entity shall display conspicuously with each electronic and printed medication formulary an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the formulary. If the Medicaid Managed Care Entity receives a report that the formulary information is inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic formulary.

(5) Each Medicaid Managed Care Entity shall include a disclosure in the electronic and requested print formularies that provides the date of publication, a statement that the formulary is up to date as of publication, and contact information for questions and requests to receive updated information.

(6) The client enrollment services broker's website shall display prominently a website URL link to each Medicaid Managed Care Entity's Plan formulary. If a Medicaid enrollee calls the client enrollment services broker with questions regarding formularies, the client enrollment services broker shall offer a brief description of what a formulary is and shall refer the Medicaid enrollee to the appropriate Medicaid Managed Care Entity regarding his or her questions about a specific entity's formulary.

(d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.

(e) Medicaid redetermination information. The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process.

(f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to:

(1) a basic description of the role of care coordination services and examples of specific care coordination activities; and

(2) how a Medicaid enrollee may request care coordination services from a Medicaid Managed Care Entity.

(g) Consumer quality comparison tool.

(1) The Department shall create a consumer quality comparison tool to assist Medicaid enrollees with Medicaid Managed Care Entity Plan selection. This tool shall provide Medicaid Managed Care Entities' individual Plan performance on a set of standardized quality performance measures. The Department shall ensure that this tool shall be accessible in both a print and online format, with the online format allowing for individuals to access additional detailed Plan performance information.

(2) At a minimum, a printed version of the consumer quality comparison tool shall be provided by the Department on an annual basis to Medicaid enrollees who are required by the Department to enroll in a Medicaid Managed Care Entity Plan during an enrollee's open enrollment period. The consumer quality comparison tool shall also meet all of the following criteria:

(A) Display Medicaid Managed Care Entities' individual Plan performance on at least 4 composite domains that reflect Plan quality, timeliness, and access. The composite domains shall draw from the most current available performance data sets including, but not limited to:

(i) Healthcare Effectiveness Data and Information Set (HEDIS) measures.

(ii) Core Set of Children's Health Care Quality measures as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA).

(iii) Adult Core Set measures.

(iv) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results.

(v) Additional performance measures the Department deems appropriate to populate the composite domains.

(B) Use a quality rating system developed by the Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.

(C) Be customized to reflect the specific Medicaid Managed Care Entities' Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(D) Include contact information for the client enrollment services broker and contact information for Medicaid Managed Care Entities available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(E) Include guiding questions designed to assist individuals selecting a Medicaid Managed Care Entity Plan.

(3) At a minimum, the online version of the consumer quality comparison tool shall meet all of the following criteria:

(A) Display Medicaid Managed Care Entities' individual Plan performance for the same composite domains selected by the Department in the printed version of the consumer quality comparison tool. The Department may display additional composite domains in the online version of the consumer quality comparison tool as appropriate.

(B) Display Medicaid Managed Care Entities' individual Plan performance on each of the standardized performance measures that contribute to each composite domain displayed on the online version of the consumer quality comparison tool.

(C) Use a quality rating system developed by the Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.

(D) Include the specific Medicaid Managed Care Entity Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(E) Include a sort function to view Medicaid Managed Care Entities' individual Plan performance by quality rating and by standardized quality performance measures.

(F) Include contact information for the client enrollment services broker and for each Medicaid Managed Care Entity.

(G) Include guiding questions designed to assist individuals in selecting a Medicaid Managed Care Entity Plan.

(H) Prominently display current notice of quality performance sanctions against Medicaid Managed Care Entities. Notice of the sanctions shall remain present on the online version of the consumer quality comparison tool until the sanctions are lifted.

(4) The online version of the consumer quality comparison tool shall be displayed prominently on the client enrollment services broker's website.

(5) In the development of the consumer quality comparison tool, the Department shall establish and publicize a formal process to collect and consider written and oral feedback from consumers, advocates, and stakeholders on aspects of the consumer quality comparison tool, including, but not limited to, the following:

(A) The standardized data sets and surveys, specific performance measures, and composite domains represented in the consumer quality comparison tool.

(B) The format and presentation of the consumer quality comparison tool.

(C) The methods undertaken by the Department to notify Medicaid enrollees of the availability of the consumer quality comparison tool.

(6) The Department shall review and update as appropriate the composite domains and performance measures represented in the print and online versions of the consumer quality comparison tool at least once every 3 years. During the Department's review process, the Department shall solicit engagement in the public feedback process described in paragraph (5).

(7) The Department shall ensure that the consumer quality comparison tool is available for consumer use as soon as possible but no later than January 1, 2018.

(h) The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.

(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.4)

Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care.

(Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.5)

Sec. 5-30.5. Managed care; automatic assignment. The Department shall, within a reasonable period of time after relevant data from managed care entities has been collected and analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes into account quality scores and other operational proficiency criteria developed, defined, and adopted by the Department, to automatically assign Medicaid enrollees served under the Family Health Plan and the Integrated Care Program and those Medicaid enrollees eligible for medical assistance pursuant to the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable Care Entities, Managed Care Community Networks, and Managed Care Organizations. The quality metrics used shall be measurable for all entities. The algorithm shall not use the quality and proficiency metrics to reassign enrollees out of any plan in which they are enrolled at the time and shall only be used if the client has not voluntarily selected a primary care physician and a managed care entity or care coordination entity. Clients shall have one opportunity within 90 calendar days after auto-assignment by algorithm to select a different managed care entity. The algorithm developed and implemented shall favor assignment into managed care entities with the highest quality scores and levels of compliance with the operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.

(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.6)

Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code.

(a) Application.

(1) This Section does not apply to the State of Illinois Medicaid Managed Care Organization Request for Proposals (2018-24-001) or any agreement, regardless of what it may be called, related to or arising from this procurement, including, but not limited to, contracts, renewals, renegotiated contracts, amendments, and change orders.

(2) This Section does not apply to Medicare-Medicaid Alignment Initiative contracts executed under Article V-F of this Code.

(b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency.

(Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.7)

Sec. 5-30.7. Encounter data guidelines; provider fee schedule.

(a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.

(b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.

(Source: P.A. 100-580, eff. 3-12-18.)

(305 ILCS 5/5-30.8)

Sec. 5-30.8. Managed care organization rate transparency.

(a) For the establishment of managed care organization (MCO) capitation base rate payments from the State, including, but not limited to: (i) hospital fee schedule reforms and updates, (ii) rates related to a single State-mandated preferred drug list, (iii) rate updates related to the State's preferred drug list, (iv) inclusion of coverage for children with special needs, (v) inclusion of coverage for children within the child welfare system, (vi) annual MCO capitation rates, and (vii) any retroactive provider fee schedule adjustments or other changes required by legislation or other actions, the Department of Healthcare and Family Services shall implement a capitation base rate setting process beginning on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following elements of transparency:

(1) The Department shall include participating MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result of any new or updated hospital fee schedules or other provider fee schedules. Additionally, the Department shall share any data or reports used to develop MCO capitation rates with participating MCOs. This data shall be comprehensive enough for MCO actuaries to recreate and verify the accuracy of the capitation base rate build-up.

(2) The Department shall not limit the number of experts that each MCO is allowed to bring to the draft capitation base rate meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.

(3) The Department and its contracted actuary shall meet with all participating MCOs simultaneously and together along with consulting actuaries contracted with statewide trade association representing a majority of Medicaid health plans at the request of the plans. Participating MCOs shall additionally, at their request, be granted individual capitation rate development meetings with the Department.

(4) (Blank).

(4.5) Effective for calendar year 2024, a quality withhold program may be established by the Department for the HealthChoice Illinois Managed Care Program or any successor program. If such program withholds a portion of the actuarially certified capitation rates, the program must meet the following criteria: (i) benchmarks must be discussed publicly, based on predetermined quality standards that align with the Department's federally approved quality strategy, and set by publication on the Department's website at least 4 months prior to the start of the calendar year; (ii) incentive measures and benchmarks must be reasonable and attainable within the measurement year; and (iii) no less than 75% of the metrics shall be tied to nationally recognized measures. Any non-nationally recognized measures shall be in the reporting category for at least 2 years of experience and evaluation for consistency among MCOs prior to setting a performance baseline. The Department shall provide MCOs with biannual industry average data on the quality withhold measures. If all the money withheld is not earned back by individual MCOs, the Department shall reallocate unearned funds among the MCOs in one or both of the following manners: based upon their quality performance or for quality and equity improvement projects. Nothing in this paragraph prohibits the Department and the MCOs from establishing any other quality performance program.

(5) Upon request, the Department shall provide written responses to questions regarding MCO capitation base rates, the capitation base development methodology, and MCO capitation rate data, and all other requests regarding capitation rates from MCOs. Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.

(b) For the development of capitation base rates for new capitation rate years:

(1) The Department shall take into account emerging experience in the development of the annual MCO capitation base rates, including, but not limited to, current-year cost and utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.

(2) No later than January 1 of each year, the Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:

(A) An initial meeting for the Department to review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.

(B) A draft rate meeting after the Department provides the MCOs with the draft capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.

(3) Prior to the submission of final capitation rates to the federal Centers for Medicare and Medicaid Services, the Department shall provide the MCOs with a final actuarial report including the final capitation base rates for the following year and subsequently conduct a final capitation base review meeting. Final capitation rates shall be marked final.

(c) For the development of capitation base rates reflecting policy changes:

(1) Unless contrary to federal law and regulation, the Department must provide notice to MCOs of any significant operational policy change no later than 60 days prior to the effective date of an operational policy change in order to give MCOs time to prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces made at the sole discretion of the Department and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.

(2) No later than 60 days after the effective date of the policy change or program implementation, the Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of that data that shall be utilized to develop capitation base rates.

(3) No later than 60 days after the effective date of the policy change or program implementation, the Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for questions to be asked and answered.

(4) No later than 60 days after the effective date of the policy change or program implementation, the Department shall provide the MCOs with draft capitation base rates and shall also conduct a draft capitation base rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(d) For the development of capitation base rates for retroactive policy or fee schedule changes:

(1) The Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of the data that shall be utilized to develop capitation base rates.

(2) The Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change. The Department shall provide opportunities for questions to be asked and answered.

(3) The Department shall provide the MCOs with draft capitation rates and shall also conduct a draft rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(4) The Department shall inform MCOs no less than quarterly of upcoming benefit and policy changes to the Medicaid program.

(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.

(Source: P.A. 103-102, eff. 1-1-24.)

(305 ILCS 5/5-30.9)

Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.

(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.10)

Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.

(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.11)

Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.

(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)