305 ILCS 5/ Illinois Public Aid Code.

(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)

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)

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)

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)

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)

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)

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)

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.)

(305 ILCS 5/5-44)

Sec. 5-44. Screening, Brief Intervention, and Referral to Treatment. As used in this Section, "SBIRT" means a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons who are at risk of developing substance use disorders or have substance use disorders including, but not limited to, an addiction to alcohol, opioids, tobacco, or cannabis. SBIRT services include all of the following:

(1) Screening to quickly assess the severity of substance use and to identify the appropriate level of treatment.

(2) Brief intervention focused on increasing insight and awareness regarding substance use and motivation toward behavioral change.

(3) Referral to treatment provided to those identified as needing more extensive treatment with access to specialty care.

SBIRT services may include, but are not limited to, the following settings and programs: primary care centers, hospital emergency rooms, hospital in-patient units, trauma centers, community behavioral health programs, and other community settings that provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

The Department of Healthcare and Family Services shall develop and seek federal approval of a SBIRT benefit for which qualified providers shall be reimbursed under the medical assistance program.

In conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, the Department of Healthcare and Family Services may develop a methodology and reimbursement rate for SBIRT services provided by qualified providers in approved settings.

For opioid specific SBIRT services provided in a hospital emergency department, the Department of Healthcare and Family Services shall develop a bundled reimbursement methodology and rate for a package of opioid treatment services, which include initiation of medication for the treatment of opioid use disorder in the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services when necessary. This package of opioid related services shall be billed on a separate claim and shall be reimbursed outside of the Enhanced Ambulatory Patient Grouping system.

(Source: P.A. 102-598, eff. 1-1-22; 102-813, eff. 5-13-22.)

(305 ILCS 5/5-45)

Sec. 5-45. Reimbursement rates; substance use disorder treatment providers and facilities. Beginning on July 1, 2022, the Department of Human Services' Division of Substance Use Prevention and Recovery in conjunction with the Department of Healthcare and Family Services, shall provide for an increase in reimbursement rates by way of an increase to existing rates of 47% for all community-based substance use disorder treatment services, including, but not limited to, all of the following:

(1) Admission and Discharge Assessment.

(2) Level 1 (Individual).

(3) Level 1 (Group).

(4) Level 2 (Individual).

(5) Level 2 (Group).

(6) Psychiatric/Diagnostic.

(7) Medication Monitoring (Individual).

(8) Methadone as an Adjunct to Treatment.

No existing or future reimbursement rates or add-ons shall be reduced or changed to address the rate increase proposed under this Section. The Department of Healthcare and Family Services shall immediately, no later than 3 months following April 19, 2022 (the effective date of Public Act 102-699), submit any necessary application to the federal Centers for Medicare and Medicaid Services for a waiver or State Plan amendment to implement the requirements of this Section. Beginning in State fiscal year 2023, and every State fiscal year thereafter, reimbursement rates for those community-based substance use disorder treatment services shall be adjusted upward by an amount equal to the Consumer Price Index-U from the previous year, not to exceed 2% in any State fiscal year. If there is a decrease in the Consumer Price Index-U, rates shall remain unchanged for that State fiscal year. The Department of Human Services shall adopt rules, including emergency rules under Section 5-45.1 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.

As used in this Section, "consumer price index-u" means the index published by the Bureau of Labor Statistics of the United States Department of Labor that measures the average change in prices of goods and services purchased by all urban consumers, United States city average, all items, 1982-84 = 100.

(Source: P.A. 102-699, eff. 4-19-22; 103-154, eff. 6-30-23.)

(305 ILCS 5/5-46)

Sec. 5-46. General acute care hospitals. A general acute care hospital is authorized to file a notice with the Department of Public Health and the Health Facilities and Services Review Board to establish an acute mental illness category of service in accordance with the Illinois Health Facilities Planning Act and add authorized acute mental illness beds if the following conditions are met:

(1) the general acute care hospital qualifies as a safety-net hospital, as defined in Section 5-5e.1, as determined by the Department of Healthcare and Family Services at the time of filing the notice or for the year immediately prior to the date of filing the notice;

(2) the notice seeks to establish no more than 24 authorized acute mental illness beds; and

(3) the notice seeks to reduce the number of authorized beds in another category of service to offset the number of authorized acute mental illness beds.

(Source: P.A. 102-886, eff. 5-17-22; 103-154, eff. 6-30-23.)

(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.)