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Illinois Compiled Statutes

Information maintained by the Legislative Reference Bureau
Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide.

Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.

PUBLIC AID
(305 ILCS 5/) Illinois Public Aid Code.

305 ILCS 5/5-34

    (305 ILCS 5/5-34)
    Sec. 5-34. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)

305 ILCS 5/5-35

    (305 ILCS 5/5-35)
    Sec. 5-35. Personal needs allowance. For a person who is a resident in a facility licensed under the ID/DD Community Care Act, the Community-Integrated Living Arrangements Licensure and Certification Act, the Specialized Mental Health Rehabilitation Act of 2013, or the MC/DD Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the State shall pay an amount in addition to the minimum monthly personal needs allowance authorized under Section 1902(q) of Title XIX of the Social Security Act (42 U.S.C. 1396(q)) so that the person's total monthly personal needs allowance from both State and federal sources equals $60.
(Source: P.A. 100-23, eff. 7-6-17.)

305 ILCS 5/5-35.5

    (305 ILCS 5/5-35.5)
    Sec. 5-35.5. Personal needs allowance; nursing home residents. Subject to federal approval, on and after January 1, 2024, for a person who is a resident in a facility licensed under the Nursing Home Care Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the monthly personal needs allowance shall be $60.
(Source: P.A. 103-102, eff. 1-1-24.)

305 ILCS 5/5-36

    (305 ILCS 5/5-36)
    Sec. 5-36. Pharmacy benefits.
    (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law.
    (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies:
        (A) the Department shall approve any contract between
    
a third-party administrator and a pharmacy;
        (B) the Department's third-party administrator shall
    
not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and
        (C) the Department's third-party administrator shall
    
not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.
    (b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
    (b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code.
    (c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
    (d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
    (e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
        (1) whether the pharmacy benefit manager has a
    
contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;
        (2) the percentage of claims payments made by the
    
pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;
        (3) the aggregate amount of the fees or assessments
    
imposed on, or collected from, pharmacy providers; and
        (4) the average annualized percentage of revenue
    
collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations.
    (f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
    (g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
    (h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
        (1) a provision prohibiting the provider from
    
informing a patient of a less costly alternative to a prescribed medication; or
        (2) a provision that prohibits the provider from
    
dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
    (h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that:
        (1) imposes any fee, chargeback, or rate adjustment
    
that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
        (2) imposes any fee, chargeback, or rate adjustment
    
that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
        (3) prevents or interferes with an individual's
    
choice to receive a prescription drug from a 340B entity or 340B pharmacy through any legally permissible means;
        (4) excludes a 340B entity or 340B pharmacy from a
    
pharmacy network on the basis of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
        (5) prevents a 340B entity or 340B pharmacy from
    
using a drug purchased under the 340B drug discount program so long as the drug recipient is a patient of the 340B entity; nothing in this Section exempts a 340B pharmacy from following the Department's preferred drug list or from any prior approval requirements of the Department or the Medicaid managed care organization that are imposed on the drug for all pharmacies; or
        (6) any other provision that discriminates against a
    
340B entity or 340B pharmacy by treating a 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity's participation in the 340B drug discount program.
    A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
    In this subsection (h-5):
    "340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
    "340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
    (i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
    (j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
    (k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)

305 ILCS 5/5-36.1

    (305 ILCS 5/5-36.1)
    Sec. 5-36.1. Earned income for residents of community-integrated living arrangements.
    (a) Beginning no later than July 1, 2021, residents of facilities licensed under the Community-Integrated Living Arrangements Licensure and Certification Act who are determined to be eligible for medical assistance under this Code and who are enrolled in the State's home and community-based services waiver program for adults with developmental disabilities shall retain all earned income from employment or community day services activities.
    (b) No portion of earned income shall be applied toward the facilities rate reimbursement methodology. The Department of Human Services shall ensure the rates of payments paid to facilities under the Code are held harmless.
(Source: P.A. 102-343, eff. 8-13-21.)

305 ILCS 5/5-36.5

    (305 ILCS 5/5-36.5)
    Sec. 5-36.5. Education on mental health and substance use treatment services for children and young adults. The Department of Healthcare and Family Services shall develop a layman's guide to the mental health and substance use treatment services available in Illinois through the Medical Assistance Program and through the Family Support Program, or other publicly funded programs, similar to what Massachusetts developed, to help families understand what services are available to them when they have a child in need of treatment or support. The guide shall be in easy-to-understand language, be prominently available on the Department of Healthcare and Family Services' website, and be part of a statewide communications campaign to ensure families are aware of Family Support Program services. It shall briefly explain the service and whether it is covered by the Medical Assistance Program, the Family Support Program, or any other public funding source. Within one year after January 1, 2020 (the effective date of Public Act 101-461), the Department of Healthcare and Family Services shall complete this guide, have it available on its website, and launch the communications campaign.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)

305 ILCS 5/5-37

    (305 ILCS 5/5-37)
    Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.
    (a) The General Assembly finds:
        (1) It is common for children to have mental health
    
needs but to not have a full-blown diagnosis of a mental illness. Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).
        (2) The federal requirement that Medicaid-covered
    
children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.
        (3) The Department of Healthcare and Family Services'
    
existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook. However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive. This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.
    (b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20.)

305 ILCS 5/5-38

    (305 ILCS 5/5-38)
    Sec. 5-38. Alignment of children's mental health treatment systems. The Governor's Office shall establish, convene, and lead a working group that includes the Director of Healthcare and Family Services, the Secretary of Human Services, the Director of Public Health, the Director of Children and Family Services, the Director of Juvenile Justice, the State Superintendent of Education, and the appropriate agency staff who will be responsible for implementation or oversight of reforms to children's behavioral health services. The working group shall meet at least quarterly to foster interagency collaboration and work toward the goal of aligning services and programs to begin to create a coordinated children's behavioral health system consistent with system of care principles that spans across State agencies, rather than separate siloed systems with different requirements, rates, and administrative processes and standards.
(Source: P.A. 101-461, eff. 1-1-20.)

305 ILCS 5/5-39

    (305 ILCS 5/5-39)
    Sec. 5-39. Behavioral health services for children; diagnostic assessment system. Beginning on July 1, 2022, if it is necessary to provide a diagnostic code for behavioral health services for children ages 5 and under, providers shall utilize a developmentally appropriate and age-appropriate diagnostic assessment system, such as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC:0-5), for diagnosis and treatment planning. If necessary for billing purposes, the provider, managed care organization, or Department shall utilize the existing crosswalk tool to convert the developmentally appropriate and age-appropriate diagnosis code to the relevant code available in the State system.
    By no later than January 1, 2022, the Department shall make recommendations to the General Assembly on the resources needed to integrate developmentally appropriate and age-appropriate diagnostic codes into the State system.
(Source: P.A. 101-654, eff. 3-8-21.)

305 ILCS 5/5-40

    (305 ILCS 5/5-40)
    Sec. 5-40. Human breast milk coverage.
    (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
        (1) the milk is obtained from a human milk bank that
    
meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
        (2) the infant's mother is medically or physically
    
unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
        (3) the milk has been determined to be medically
    
necessary for the infant; and
        (4) one or more of the following applies:
            (A) the infant's birth weight is below 1,500
        
grams;
            (B) the infant has a congenital or acquired
        
condition that places the infant at a high risk for development of necrotizing enterocolitis;
            (C) the infant has infant hypoglycemia;
            (D) the infant has congenital heart disease;
            (E) the infant has had or will have an organ
        
transplant;
            (F) the infant has sepsis; or
            (G) the infant has any other serious congenital
        
or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
    (b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
        (1) the milk is obtained from a human milk bank that
    
meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
        (2) the child's mother is medically or physically
    
unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
        (3) the milk has been determined to be medically
    
necessary for the child; and
        (4) one or more of the following applies:
            (A) the child has spinal muscular atrophy;
            (B) the child's birth weight was below 1,500
        
grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
            (C) the child has had or will have an organ
        
transplant; or
            (D) the child has a congenital or acquired
        
condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
    (c) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 12 months of age or older, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
        (1) the milk is obtained from a human milk bank that
    
meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
        (2) the child's mother is medically or physically
    
unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
        (3) the milk has been determined to be medically
    
necessary for the child; and
        (4) the child has spinal muscular atrophy.
(Source: P.A. 101-511, eff. 1-1-20.)

305 ILCS 5/5-41

    (305 ILCS 5/5-41)
    Sec. 5-41. Inpatient hospitalization for opioid-related overdose or withdrawal patients. Due to the disproportionately high opioid-related fatality rates among African Americans in under-resourced communities in Illinois, the lack of community resources, the comorbidities experienced by these patients, and the high rate of hospital inpatient recidivism associated with this population when improperly treated, the Department shall ensure that patients, whether enrolled under the Medical Assistance Fee For Service program or enrolled with a Medicaid Managed Care Organization, experiencing opioid-related overdose or withdrawal are admitted on an inpatient status and the provider shall be reimbursed accordingly, when deemed medically necessary, as determined by either the patient's primary care physician, or the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, using criteria established by the American Society of Addiction Medicine. If it is determined by the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, that a patient does not meet medical necessity criteria for the admission, then the patient may be treated via observation and the provider shall seek reimbursement accordingly. Nothing in this Section shall diminish the requirements of a provider to document medical necessity in the patient's record.
(Source: P.A. 102-43, eff. 7-6-21; 102-813, eff. 5-13-22.)

305 ILCS 5/5-42

    (305 ILCS 5/5-42)
    Sec. 5-42. Tobacco cessation coverage; 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 all tobacco cessation medications approved by the United States Food and Drug Administration, all individual and group tobacco cessation counseling services, and all telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline. The Department may adopt any rules necessary to implement this Section.
(Source: P.A. 102-43, eff. 7-6-21.)

305 ILCS 5/5-43

    (305 ILCS 5/5-43)
    Sec. 5-43. Supports Waiver Program for Young Adults with Developmental Disabilities.
    (a) The Department of Human Services' Division of Developmental Disabilities, in partnership with the Department of Healthcare and Family Services and stakeholders, shall study the development and implementation of a supports waiver program for young adults with developmental disabilities. The Division shall explore the following components of a supports waiver program to determine what is most appropriate:
        (1) The age of individuals to be provided services in
    
a waiver program.
        (2) The number of individuals to be provided services
    
in a waiver program.
        (3) The services to be provided in a waiver program.
        (4) The funding to be provided to individuals within
    
a waiver program.
        (5) The transition process to the Waiver for Adults
    
with Developmental Disabilities.
        (6) The type of home and community-based services
    
waiver to be utilized.
    (b) The Department of Human Services and the Department of Healthcare and Family Services are authorized to adopt and implement any rules necessary to study the supports waiver program.
    (c) Subject to appropriation, no later than January 1, 2024, the Department of Healthcare and Family Services shall apply to the federal Centers for Medicare and Medicaid Services for a supports waiver for young adults with developmental disabilities utilizing the information learned from the study under subsection (a).
(Source: P.A. 102-43, eff. 7-6-21.)