305 ILCS 5/ Illinois Public Aid Code.

(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.)