Rep. Nabeela Syed

Filed: 3/4/2024

 

 


 

 


 
10300HB4180ham001LRB103 34255 RPS 70122 a

1
AMENDMENT TO HOUSE BILL 4180

2    AMENDMENT NO. ______. Amend House Bill 4180 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    Sec. 356g. Mammograms; mastectomies.
8    (a) Every insurer shall provide in each group or
9individual policy, contract, or certificate of insurance
10issued or renewed for persons who are residents of this State,
11coverage for screening by low-dose mammography for all
12patients women 35 years of age or older for the presence of
13occult breast cancer within the provisions of the policy,
14contract, or certificate. The coverage shall be as follows:
15         (1) A baseline mammogram for patients women 35 to 39
16    years of age.

 

 

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1         (2) An annual mammogram for patients women 40 years
2    of age or older.
3         (3) A mammogram at the age and intervals considered
4    medically necessary by the patient's woman's health care
5    provider for patients women under 40 years of age and
6    having a family history of breast cancer, prior personal
7    history of breast cancer, positive genetic testing, or
8    other risk factors.
9        (4) For an individual or group policy of accident and
10    health insurance or a managed care plan that is amended,
11    delivered, issued, or renewed on or after January 1, 2026
12    the effective date of this amendatory Act of the 101st
13    General Assembly, a comprehensive ultrasound screening,
14    and MRI, and molecular breast imaging (MBI) of an entire
15    breast or breasts if a mammogram demonstrates
16    heterogeneous or dense breast tissue or when medically
17    necessary as determined by a physician licensed to
18    practice medicine in all of its branches.
19        (5) A screening MRI when medically necessary, as
20    determined by a physician licensed to practice medicine in
21    all of its branches.
22        (6) For an individual or group policy of accident and
23    health insurance or a managed care plan that is amended,
24    delivered, issued, or renewed on or after January 1, 2020
25    (the effective date of Public Act 101-580) this amendatory
26    Act of the 101st General Assembly, a diagnostic mammogram

 

 

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1    when medically necessary, as determined by a physician
2    licensed to practice medicine in all its branches,
3    advanced practice registered nurse, or physician
4    assistant.
5    A policy subject to this subsection shall not impose a
6deductible, coinsurance, copayment, or any other cost-sharing
7requirement on the coverage provided; except that this
8sentence does not apply to coverage of diagnostic mammograms
9to the extent such coverage would disqualify a high-deductible
10health plan from eligibility for a health savings account
11pursuant to Section 223 of the Internal Revenue Code (26
12U.S.C. 223).
13    For purposes of this Section:
14    "Diagnostic mammogram" means a mammogram obtained using
15diagnostic mammography.
16    "Diagnostic mammography" means a method of screening that
17is designed to evaluate an abnormality in a breast, including
18an abnormality seen or suspected on a screening mammogram or a
19subjective or objective abnormality otherwise detected in the
20breast.
21    "Low-dose mammography" means the x-ray examination of the
22breast using equipment dedicated specifically for mammography,
23including the x-ray tube, filter, compression device, and
24image receptor, with radiation exposure delivery of less than
251 rad per breast for 2 views of an average size breast. The
26term also includes digital mammography and includes breast

 

 

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1tomosynthesis. As used in this Section, the term "breast
2tomosynthesis" means a radiologic procedure that involves the
3acquisition of projection images over the stationary breast to
4produce cross-sectional digital three-dimensional images of
5the breast.
6    If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage for breast tomosynthesis outlined in this
16subsection, then the requirement that an insurer cover breast
17tomosynthesis is inoperative other than any such coverage
18authorized under Section 1902 of the Social Security Act, 42
19U.S.C. 1396a, and the State shall not assume any obligation
20for the cost of coverage for breast tomosynthesis set forth in
21this subsection.
22    (a-5) Coverage as described by subsection (a) shall be
23provided at no cost to the insured and shall not be applied to
24an annual or lifetime maximum benefit.
25    (a-10) When health care services are available through
26contracted providers and a person does not comply with plan

 

 

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1provisions specific to the use of contracted providers, the
2requirements of subsection (a-5) are not applicable. When a
3person does not comply with plan provisions specific to the
4use of contracted providers, plan provisions specific to the
5use of non-contracted providers must be applied without
6distinction for coverage required by this Section and shall be
7at least as favorable as for other radiological examinations
8covered by the policy or contract.
9    (b) No policy of accident or health insurance that
10provides for the surgical procedure known as a mastectomy
11shall be issued, amended, delivered, or renewed in this State
12unless that coverage also provides for prosthetic devices or
13reconstructive surgery incident to the mastectomy. Coverage
14for breast reconstruction in connection with a mastectomy
15shall include:
16        (1) reconstruction of the breast upon which the
17    mastectomy has been performed;
18        (2) surgery and reconstruction of the other breast to
19    produce a symmetrical appearance; and
20        (3) prostheses and treatment for physical
21    complications at all stages of mastectomy, including
22    lymphedemas.
23Care shall be determined in consultation with the attending
24physician and the patient. The offered coverage for prosthetic
25devices and reconstructive surgery shall be subject to the
26deductible and coinsurance conditions applied to the

 

 

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1mastectomy, and all other terms and conditions applicable to
2other benefits. When a mastectomy is performed and there is no
3evidence of malignancy then the offered coverage may be
4limited to the provision of prosthetic devices and
5reconstructive surgery to within 2 years after the date of the
6mastectomy. As used in this Section, "mastectomy" means the
7removal of all or part of the breast for medically necessary
8reasons, as determined by a licensed physician.
9    Written notice of the availability of coverage under this
10Section shall be delivered to the insured upon enrollment and
11annually thereafter. An insurer may not deny to an insured
12eligibility, or continued eligibility, to enroll or to renew
13coverage under the terms of the plan solely for the purpose of
14avoiding the requirements of this Section. An insurer may not
15penalize or reduce or limit the reimbursement of an attending
16provider or provide incentives (monetary or otherwise) to an
17attending provider to induce the provider to provide care to
18an insured in a manner inconsistent with this Section.
19    (c) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in
21accordance with all provisions of the Illinois Administrative
22Procedure Act and all rules and procedures of the Joint
23Committee on Administrative Rules; any purported rule not so
24adopted, for whatever reason, is unauthorized.
25(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
 

 

 

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1    Section 10. The Health Maintenance Organization Act is
2amended by changing Section 5-3 as follows:
 
3    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
4    Sec. 5-3. Insurance Code provisions.
5    (a) Health Maintenance Organizations shall be subject to
6the provisions of Sections 133, 134, 136, 137, 139, 140,
7141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
8154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
9355.2, 355.3, 355b, 355c, 356f, 356g, 356g.5-1, 356m, 356q,
10356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
11356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
12356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
13356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
14356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
15356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
16356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
17356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
18356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
19356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
20368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
21408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
22subsection (2) of Section 367, and Articles IIA, VIII 1/2,
23XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
24Illinois Insurance Code.
25    (b) For purposes of the Illinois Insurance Code, except

 

 

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1for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
2Health Maintenance Organizations in the following categories
3are deemed to be "domestic companies":
4        (1) a corporation authorized under the Dental Service
5    Plan Act or the Voluntary Health Services Plans Act;
6        (2) a corporation organized under the laws of this
7    State; or
8        (3) a corporation organized under the laws of another
9    state, 30% or more of the enrollees of which are residents
10    of this State, except a corporation subject to
11    substantially the same requirements in its state of
12    organization as is a "domestic company" under Article VIII
13    1/2 of the Illinois Insurance Code.
14    (c) In considering the merger, consolidation, or other
15acquisition of control of a Health Maintenance Organization
16pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17        (1) the Director shall give primary consideration to
18    the continuation of benefits to enrollees and the
19    financial conditions of the acquired Health Maintenance
20    Organization after the merger, consolidation, or other
21    acquisition of control takes effect;
22        (2)(i) the criteria specified in subsection (1)(b) of
23    Section 131.8 of the Illinois Insurance Code shall not
24    apply and (ii) the Director, in making his determination
25    with respect to the merger, consolidation, or other
26    acquisition of control, need not take into account the

 

 

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1    effect on competition of the merger, consolidation, or
2    other acquisition of control;
3        (3) the Director shall have the power to require the
4    following information:
5            (A) certification by an independent actuary of the
6        adequacy of the reserves of the Health Maintenance
7        Organization sought to be acquired;
8            (B) pro forma financial statements reflecting the
9        combined balance sheets of the acquiring company and
10        the Health Maintenance Organization sought to be
11        acquired as of the end of the preceding year and as of
12        a date 90 days prior to the acquisition, as well as pro
13        forma financial statements reflecting projected
14        combined operation for a period of 2 years;
15            (C) a pro forma business plan detailing an
16        acquiring party's plans with respect to the operation
17        of the Health Maintenance Organization sought to be
18        acquired for a period of not less than 3 years; and
19            (D) such other information as the Director shall
20        require.
21    (d) The provisions of Article VIII 1/2 of the Illinois
22Insurance Code and this Section 5-3 shall apply to the sale by
23any health maintenance organization of greater than 10% of its
24enrollee population (including, without limitation, the health
25maintenance organization's right, title, and interest in and
26to its health care certificates).

 

 

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1    (e) In considering any management contract or service
2agreement subject to Section 141.1 of the Illinois Insurance
3Code, the Director (i) shall, in addition to the criteria
4specified in Section 141.2 of the Illinois Insurance Code,
5take into account the effect of the management contract or
6service agreement on the continuation of benefits to enrollees
7and the financial condition of the health maintenance
8organization to be managed or serviced, and (ii) need not take
9into account the effect of the management contract or service
10agreement on competition.
11    (f) Except for small employer groups as defined in the
12Small Employer Rating, Renewability and Portability Health
13Insurance Act and except for medicare supplement policies as
14defined in Section 363 of the Illinois Insurance Code, a
15Health Maintenance Organization may by contract agree with a
16group or other enrollment unit to effect refunds or charge
17additional premiums under the following terms and conditions:
18        (i) the amount of, and other terms and conditions with
19    respect to, the refund or additional premium are set forth
20    in the group or enrollment unit contract agreed in advance
21    of the period for which a refund is to be paid or
22    additional premium is to be charged (which period shall
23    not be less than one year); and
24        (ii) the amount of the refund or additional premium
25    shall not exceed 20% of the Health Maintenance
26    Organization's profitable or unprofitable experience with

 

 

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1    respect to the group or other enrollment unit for the
2    period (and, for purposes of a refund or additional
3    premium, the profitable or unprofitable experience shall
4    be calculated taking into account a pro rata share of the
5    Health Maintenance Organization's administrative and
6    marketing expenses, but shall not include any refund to be
7    made or additional premium to be paid pursuant to this
8    subsection (f)). The Health Maintenance Organization and
9    the group or enrollment unit may agree that the profitable
10    or unprofitable experience may be calculated taking into
11    account the refund period and the immediately preceding 2
12    plan years.
13    The Health Maintenance Organization shall include a
14statement in the evidence of coverage issued to each enrollee
15describing the possibility of a refund or additional premium,
16and upon request of any group or enrollment unit, provide to
17the group or enrollment unit a description of the method used
18to calculate (1) the Health Maintenance Organization's
19profitable experience with respect to the group or enrollment
20unit and the resulting refund to the group or enrollment unit
21or (2) the Health Maintenance Organization's unprofitable
22experience with respect to the group or enrollment unit and
23the resulting additional premium to be paid by the group or
24enrollment unit.
25    In no event shall the Illinois Health Maintenance
26Organization Guaranty Association be liable to pay any

 

 

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1contractual obligation of an insolvent organization to pay any
2refund authorized under this Section.
3    (g) Rulemaking authority to implement Public Act 95-1045,
4if any, is conditioned on the rules being adopted in
5accordance with all provisions of the Illinois Administrative
6Procedure Act and all rules and procedures of the Joint
7Committee on Administrative Rules; any purported rule not so
8adopted, for whatever reason, is unauthorized.
9(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
10102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
111-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
12eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
13102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
141-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
15eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
16103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
176-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
18eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
19    Section 15. The Illinois Public Aid Code is amended by
20changing Section 5-5 as follows:
 
21    (305 ILCS 5/5-5)
22    Sec. 5-5. Medical services. The Illinois Department, by
23rule, shall determine the quantity and quality of and the rate
24of reimbursement for the medical assistance for which payment

 

 

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1will be authorized, and the medical services to be provided,
2which may include all or part of the following: (1) inpatient
3hospital services; (2) outpatient hospital services; (3) other
4laboratory and X-ray services; (4) skilled nursing home
5services; (5) physicians' services whether furnished in the
6office, the patient's home, a hospital, a skilled nursing
7home, or elsewhere; (6) medical care, or any other type of
8remedial care furnished by licensed practitioners; (7) home
9health care services; (8) private duty nursing service; (9)
10clinic services; (10) dental services, including prevention
11and treatment of periodontal disease and dental caries disease
12for pregnant individuals, provided by an individual licensed
13to practice dentistry or dental surgery; for purposes of this
14item (10), "dental services" means diagnostic, preventive, or
15corrective procedures provided by or under the supervision of
16a dentist in the practice of his or her profession; (11)
17physical therapy and related services; (12) prescribed drugs,
18dentures, and prosthetic devices; and eyeglasses prescribed by
19a physician skilled in the diseases of the eye, or by an
20optometrist, whichever the person may select; (13) other
21diagnostic, screening, preventive, and rehabilitative
22services, including to ensure that the individual's need for
23intervention or treatment of mental disorders or substance use
24disorders or co-occurring mental health and substance use
25disorders is determined using a uniform screening, assessment,
26and evaluation process inclusive of criteria, for children and

 

 

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1adults; for purposes of this item (13), a uniform screening,
2assessment, and evaluation process refers to a process that
3includes an appropriate evaluation and, as warranted, a
4referral; "uniform" does not mean the use of a singular
5instrument, tool, or process that all must utilize; (14)
6transportation and such other expenses as may be necessary;
7(15) medical treatment of sexual assault survivors, as defined
8in Section 1a of the Sexual Assault Survivors Emergency
9Treatment Act, for injuries sustained as a result of the
10sexual assault, including examinations and laboratory tests to
11discover evidence which may be used in criminal proceedings
12arising from the sexual assault; (16) the diagnosis and
13treatment of sickle cell anemia; (16.5) services performed by
14a chiropractic physician licensed under the Medical Practice
15Act of 1987 and acting within the scope of his or her license,
16including, but not limited to, chiropractic manipulative
17treatment; and (17) any other medical care, and any other type
18of remedial care recognized under the laws of this State. The
19term "any other type of remedial care" shall include nursing
20care and nursing home service for persons who rely on
21treatment by spiritual means alone through prayer for healing.
22    Notwithstanding any other provision of this Section, a
23comprehensive tobacco use cessation program that includes
24purchasing prescription drugs or prescription medical devices
25approved by the Food and Drug Administration shall be covered
26under the medical assistance program under this Article for

 

 

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1persons who are otherwise eligible for assistance under this
2Article.
3    Notwithstanding any other provision of this Code,
4reproductive health care that is otherwise legal in Illinois
5shall be covered under the medical assistance program for
6persons who are otherwise eligible for medical assistance
7under this Article.
8    Notwithstanding any other provision of this Section, all
9tobacco cessation medications approved by the United States
10Food and Drug Administration and all individual and group
11tobacco cessation counseling services and telephone-based
12counseling services and tobacco cessation medications provided
13through the Illinois Tobacco Quitline shall be covered under
14the medical assistance program for persons who are otherwise
15eligible for assistance under this Article. The Department
16shall comply with all federal requirements necessary to obtain
17federal financial participation, as specified in 42 CFR
18433.15(b)(7), for telephone-based counseling services provided
19through the Illinois Tobacco Quitline, including, but not
20limited to: (i) entering into a memorandum of understanding or
21interagency agreement with the Department of Public Health, as
22administrator of the Illinois Tobacco Quitline; and (ii)
23developing a cost allocation plan for Medicaid-allowable
24Illinois Tobacco Quitline services in accordance with 45 CFR
2595.507. The Department shall submit the memorandum of
26understanding or interagency agreement, the cost allocation

 

 

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1plan, and all other necessary documentation to the Centers for
2Medicare and Medicaid Services for review and approval.
3Coverage under this paragraph shall be contingent upon federal
4approval.
5    Notwithstanding any other provision of this Code, the
6Illinois Department may not require, as a condition of payment
7for any laboratory test authorized under this Article, that a
8physician's handwritten signature appear on the laboratory
9test order form. The Illinois Department may, however, impose
10other appropriate requirements regarding laboratory test order
11documentation.
12    Upon receipt of federal approval of an amendment to the
13Illinois Title XIX State Plan for this purpose, the Department
14shall authorize the Chicago Public Schools (CPS) to procure a
15vendor or vendors to manufacture eyeglasses for individuals
16enrolled in a school within the CPS system. CPS shall ensure
17that its vendor or vendors are enrolled as providers in the
18medical assistance program and in any capitated Medicaid
19managed care entity (MCE) serving individuals enrolled in a
20school within the CPS system. Under any contract procured
21under this provision, the vendor or vendors must serve only
22individuals enrolled in a school within the CPS system. Claims
23for services provided by CPS's vendor or vendors to recipients
24of benefits in the medical assistance program under this Code,
25the Children's Health Insurance Program, or the Covering ALL
26KIDS Health Insurance Program shall be submitted to the

 

 

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1Department or the MCE in which the individual is enrolled for
2payment and shall be reimbursed at the Department's or the
3MCE's established rates or rate methodologies for eyeglasses.
4    On and after July 1, 2012, the Department of Healthcare
5and Family Services may provide the following services to
6persons eligible for assistance under this Article who are
7participating in education, training or employment programs
8operated by the Department of Human Services as successor to
9the Department of Public Aid:
10        (1) dental services provided by or under the
11    supervision of a dentist; and
12        (2) eyeglasses prescribed by a physician skilled in
13    the diseases of the eye, or by an optometrist, whichever
14    the person may select.
15    On and after July 1, 2018, the Department of Healthcare
16and Family Services shall provide dental services to any adult
17who is otherwise eligible for assistance under the medical
18assistance program. As used in this paragraph, "dental
19services" means diagnostic, preventative, restorative, or
20corrective procedures, including procedures and services for
21the prevention and treatment of periodontal disease and dental
22caries disease, provided by an individual who is licensed to
23practice dentistry or dental surgery or who is under the
24supervision of a dentist in the practice of his or her
25profession.
26    On and after July 1, 2018, targeted dental services, as

 

 

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1set forth in Exhibit D of the Consent Decree entered by the
2United States District Court for the Northern District of
3Illinois, Eastern Division, in the matter of Memisovski v.
4Maram, Case No. 92 C 1982, that are provided to adults under
5the medical assistance program shall be established at no less
6than the rates set forth in the "New Rate" column in Exhibit D
7of the Consent Decree for targeted dental services that are
8provided to persons under the age of 18 under the medical
9assistance program.
10    Notwithstanding any other provision of this Code and
11subject to federal approval, the Department may adopt rules to
12allow a dentist who is volunteering his or her service at no
13cost to render dental services through an enrolled
14not-for-profit health clinic without the dentist personally
15enrolling as a participating provider in the medical
16assistance program. A not-for-profit health clinic shall
17include a public health clinic or Federally Qualified Health
18Center or other enrolled provider, as determined by the
19Department, through which dental services covered under this
20Section are performed. The Department shall establish a
21process for payment of claims for reimbursement for covered
22dental services rendered under this provision.
23    On and after January 1, 2022, the Department of Healthcare
24and Family Services shall administer and regulate a
25school-based dental program that allows for the out-of-office
26delivery of preventative dental services in a school setting

 

 

10300HB4180ham001- 19 -LRB103 34255 RPS 70122 a

1to children under 19 years of age. The Department shall
2establish, by rule, guidelines for participation by providers
3and set requirements for follow-up referral care based on the
4requirements established in the Dental Office Reference Manual
5published by the Department that establishes the requirements
6for dentists participating in the All Kids Dental School
7Program. Every effort shall be made by the Department when
8developing the program requirements to consider the different
9geographic differences of both urban and rural areas of the
10State for initial treatment and necessary follow-up care. No
11provider shall be charged a fee by any unit of local government
12to participate in the school-based dental program administered
13by the Department. Nothing in this paragraph shall be
14construed to limit or preempt a home rule unit's or school
15district's authority to establish, change, or administer a
16school-based dental program in addition to, or independent of,
17the school-based dental program administered by the
18Department.
19    The Illinois Department, by rule, may distinguish and
20classify the medical services to be provided only in
21accordance with the classes of persons designated in Section
225-2.
23    The Department of Healthcare and Family Services must
24provide coverage and reimbursement for amino acid-based
25elemental formulas, regardless of delivery method, for the
26diagnosis and treatment of (i) eosinophilic disorders and (ii)

 

 

10300HB4180ham001- 20 -LRB103 34255 RPS 70122 a

1short bowel syndrome when the prescribing physician has issued
2a written order stating that the amino acid-based elemental
3formula is medically necessary.
4    The Illinois Department shall authorize the provision of,
5and shall authorize payment for, screening by low-dose
6mammography for the presence of occult breast cancer for
7individuals 35 years of age or older who are eligible for
8medical assistance under this Article, as follows:
9        (A) A baseline mammogram for individuals 35 to 39
10    years of age.
11        (B) An annual mammogram for individuals 40 years of
12    age or older.
13        (C) A mammogram at the age and intervals considered
14    medically necessary by the individual's health care
15    provider for individuals under 40 years of age and having
16    a family history of breast cancer, prior personal history
17    of breast cancer, positive genetic testing, or other risk
18    factors.
19        (D) A comprehensive ultrasound screening, molecular
20    breast imaging (MBI), and MRI of an entire breast or
21    breasts if a mammogram demonstrates heterogeneous or dense
22    breast tissue or when medically necessary as determined by
23    a physician licensed to practice medicine in all of its
24    branches.
25        (E) A screening MRI when medically necessary, as
26    determined by a physician licensed to practice medicine in

 

 

10300HB4180ham001- 21 -LRB103 34255 RPS 70122 a

1    all of its branches.
2        (F) A diagnostic mammogram when medically necessary,
3    as determined by a physician licensed to practice medicine
4    in all its branches, advanced practice registered nurse,
5    or physician assistant.
6    The Department shall not impose a deductible, coinsurance,
7copayment, or any other cost-sharing requirement on the
8coverage provided under this paragraph; except that this
9sentence does not apply to coverage of diagnostic mammograms
10to the extent such coverage would disqualify a high-deductible
11health plan from eligibility for a health savings account
12pursuant to Section 223 of the Internal Revenue Code (26
13U.S.C. 223).
14    All screenings shall include a physical breast exam,
15instruction on self-examination and information regarding the
16frequency of self-examination and its value as a preventative
17tool.
18     For purposes of this Section:
19    "Diagnostic mammogram" means a mammogram obtained using
20diagnostic mammography.
21    "Diagnostic mammography" means a method of screening that
22is designed to evaluate an abnormality in a breast, including
23an abnormality seen or suspected on a screening mammogram or a
24subjective or objective abnormality otherwise detected in the
25breast.
26    "Low-dose mammography" means the x-ray examination of the

 

 

10300HB4180ham001- 22 -LRB103 34255 RPS 70122 a

1breast using equipment dedicated specifically for mammography,
2including the x-ray tube, filter, compression device, and
3image receptor, with an average radiation exposure delivery of
4less than one rad per breast for 2 views of an average size
5breast. The term also includes digital mammography and
6includes breast tomosynthesis.
7    "Breast tomosynthesis" means a radiologic procedure that
8involves the acquisition of projection images over the
9stationary breast to produce cross-sectional digital
10three-dimensional images of the breast.
11    If, at any time, the Secretary of the United States
12Department of Health and Human Services, or its successor
13agency, promulgates rules or regulations to be published in
14the Federal Register or publishes a comment in the Federal
15Register or issues an opinion, guidance, or other action that
16would require the State, pursuant to any provision of the
17Patient Protection and Affordable Care Act (Public Law
18111-148), including, but not limited to, 42 U.S.C.
1918031(d)(3)(B) or any successor provision, to defray the cost
20of any coverage for breast tomosynthesis outlined in this
21paragraph, then the requirement that an insurer cover breast
22tomosynthesis is inoperative other than any such coverage
23authorized under Section 1902 of the Social Security Act, 42
24U.S.C. 1396a, and the State shall not assume any obligation
25for the cost of coverage for breast tomosynthesis set forth in
26this paragraph.

 

 

10300HB4180ham001- 23 -LRB103 34255 RPS 70122 a

1    On and after January 1, 2016, the Department shall ensure
2that all networks of care for adult clients of the Department
3include access to at least one breast imaging Center of
4Imaging Excellence as certified by the American College of
5Radiology.
6    On and after January 1, 2012, providers participating in a
7quality improvement program approved by the Department shall
8be reimbursed for screening and diagnostic mammography at the
9same rate as the Medicare program's rates, including the
10increased reimbursement for digital mammography and, after
11January 1, 2023 (the effective date of Public Act 102-1018),
12breast tomosynthesis.
13    The Department shall convene an expert panel including
14representatives of hospitals, free-standing mammography
15facilities, and doctors, including radiologists, to establish
16quality standards for mammography.
17    On and after January 1, 2017, providers participating in a
18breast cancer treatment quality improvement program approved
19by the Department shall be reimbursed for breast cancer
20treatment at a rate that is no lower than 95% of the Medicare
21program's rates for the data elements included in the breast
22cancer treatment quality program.
23    The Department shall convene an expert panel, including
24representatives of hospitals, free-standing breast cancer
25treatment centers, breast cancer quality organizations, and
26doctors, including radiologists that are trained in all forms

 

 

10300HB4180ham001- 24 -LRB103 34255 RPS 70122 a

1of FDA approved breast imaging technologies, breast surgeons,
2reconstructive breast surgeons, oncologists, and primary care
3providers to establish quality standards for breast cancer
4treatment.
5    Subject to federal approval, the Department shall
6establish a rate methodology for mammography at federally
7qualified health centers and other encounter-rate clinics.
8These clinics or centers may also collaborate with other
9hospital-based mammography facilities. By January 1, 2016, the
10Department shall report to the General Assembly on the status
11of the provision set forth in this paragraph.
12    The Department shall establish a methodology to remind
13individuals who are age-appropriate for screening mammography,
14but who have not received a mammogram within the previous 18
15months, of the importance and benefit of screening
16mammography. The Department shall work with experts in breast
17cancer outreach and patient navigation to optimize these
18reminders and shall establish a methodology for evaluating
19their effectiveness and modifying the methodology based on the
20evaluation.
21    The Department shall establish a performance goal for
22primary care providers with respect to their female patients
23over age 40 receiving an annual mammogram. This performance
24goal shall be used to provide additional reimbursement in the
25form of a quality performance bonus to primary care providers
26who meet that goal.

 

 

10300HB4180ham001- 25 -LRB103 34255 RPS 70122 a

1    The Department shall devise a means of case-managing or
2patient navigation for beneficiaries diagnosed with breast
3cancer. This program shall initially operate as a pilot
4program in areas of the State with the highest incidence of
5mortality related to breast cancer. At least one pilot program
6site shall be in the metropolitan Chicago area and at least one
7site shall be outside the metropolitan Chicago area. On or
8after July 1, 2016, the pilot program shall be expanded to
9include one site in western Illinois, one site in southern
10Illinois, one site in central Illinois, and 4 sites within
11metropolitan Chicago. An evaluation of the pilot program shall
12be carried out measuring health outcomes and cost of care for
13those served by the pilot program compared to similarly
14situated patients who are not served by the pilot program.
15    The Department shall require all networks of care to
16develop a means either internally or by contract with experts
17in navigation and community outreach to navigate cancer
18patients to comprehensive care in a timely fashion. The
19Department shall require all networks of care to include
20access for patients diagnosed with cancer to at least one
21academic commission on cancer-accredited cancer program as an
22in-network covered benefit.
23    The Department shall provide coverage and reimbursement
24for a human papillomavirus (HPV) vaccine that is approved for
25marketing by the federal Food and Drug Administration for all
26persons between the ages of 9 and 45. Subject to federal

 

 

10300HB4180ham001- 26 -LRB103 34255 RPS 70122 a

1approval, the Department shall provide coverage and
2reimbursement for a human papillomavirus (HPV) vaccine for
3persons of the age of 46 and above who have been diagnosed with
4cervical dysplasia with a high risk of recurrence or
5progression. The Department shall disallow any
6preauthorization requirements for the administration of the
7human papillomavirus (HPV) vaccine.
8    On or after July 1, 2022, individuals who are otherwise
9eligible for medical assistance under this Article shall
10receive coverage for perinatal depression screenings for the
1112-month period beginning on the last day of their pregnancy.
12Medical assistance coverage under this paragraph shall be
13conditioned on the use of a screening instrument approved by
14the Department.
15    Any medical or health care provider shall immediately
16recommend, to any pregnant individual who is being provided
17prenatal services and is suspected of having a substance use
18disorder as defined in the Substance Use Disorder Act,
19referral to a local substance use disorder treatment program
20licensed by the Department of Human Services or to a licensed
21hospital which provides substance abuse treatment services.
22The Department of Healthcare and Family Services shall assure
23coverage for the cost of treatment of the drug abuse or
24addiction for pregnant recipients in accordance with the
25Illinois Medicaid Program in conjunction with the Department
26of Human Services.

 

 

10300HB4180ham001- 27 -LRB103 34255 RPS 70122 a

1    All medical providers providing medical assistance to
2pregnant individuals under this Code shall receive information
3from the Department on the availability of services under any
4program providing case management services for addicted
5individuals, including information on appropriate referrals
6for other social services that may be needed by addicted
7individuals in addition to treatment for addiction.
8    The Illinois Department, in cooperation with the
9Departments of Human Services (as successor to the Department
10of Alcoholism and Substance Abuse) and Public Health, through
11a public awareness campaign, may provide information
12concerning treatment for alcoholism and drug abuse and
13addiction, prenatal health care, and other pertinent programs
14directed at reducing the number of drug-affected infants born
15to recipients of medical assistance.
16    Neither the Department of Healthcare and Family Services
17nor the Department of Human Services shall sanction the
18recipient solely on the basis of the recipient's substance
19abuse.
20    The Illinois Department shall establish such regulations
21governing the dispensing of health services under this Article
22as it shall deem appropriate. The Department should seek the
23advice of formal professional advisory committees appointed by
24the Director of the Illinois Department for the purpose of
25providing regular advice on policy and administrative matters,
26information dissemination and educational activities for

 

 

10300HB4180ham001- 28 -LRB103 34255 RPS 70122 a

1medical and health care providers, and consistency in
2procedures to the Illinois Department.
3    The Illinois Department may develop and contract with
4Partnerships of medical providers to arrange medical services
5for persons eligible under Section 5-2 of this Code.
6Implementation of this Section may be by demonstration
7projects in certain geographic areas. The Partnership shall be
8represented by a sponsor organization. The Department, by
9rule, shall develop qualifications for sponsors of
10Partnerships. Nothing in this Section shall be construed to
11require that the sponsor organization be a medical
12organization.
13    The sponsor must negotiate formal written contracts with
14medical providers for physician services, inpatient and
15outpatient hospital care, home health services, treatment for
16alcoholism and substance abuse, and other services determined
17necessary by the Illinois Department by rule for delivery by
18Partnerships. Physician services must include prenatal and
19obstetrical care. The Illinois Department shall reimburse
20medical services delivered by Partnership providers to clients
21in target areas according to provisions of this Article and
22the Illinois Health Finance Reform Act, except that:
23        (1) Physicians participating in a Partnership and
24    providing certain services, which shall be determined by
25    the Illinois Department, to persons in areas covered by
26    the Partnership may receive an additional surcharge for

 

 

10300HB4180ham001- 29 -LRB103 34255 RPS 70122 a

1    such services.
2        (2) The Department may elect to consider and negotiate
3    financial incentives to encourage the development of
4    Partnerships and the efficient delivery of medical care.
5        (3) Persons receiving medical services through
6    Partnerships may receive medical and case management
7    services above the level usually offered through the
8    medical assistance program.
9    Medical providers shall be required to meet certain
10qualifications to participate in Partnerships to ensure the
11delivery of high quality medical services. These
12qualifications shall be determined by rule of the Illinois
13Department and may be higher than qualifications for
14participation in the medical assistance program. Partnership
15sponsors may prescribe reasonable additional qualifications
16for participation by medical providers, only with the prior
17written approval of the Illinois Department.
18    Nothing in this Section shall limit the free choice of
19practitioners, hospitals, and other providers of medical
20services by clients. In order to ensure patient freedom of
21choice, the Illinois Department shall immediately promulgate
22all rules and take all other necessary actions so that
23provided services may be accessed from therapeutically
24certified optometrists to the full extent of the Illinois
25Optometric Practice Act of 1987 without discriminating between
26service providers.

 

 

10300HB4180ham001- 30 -LRB103 34255 RPS 70122 a

1    The Department shall apply for a waiver from the United
2States Health Care Financing Administration to allow for the
3implementation of Partnerships under this Section.
4    The Illinois Department shall require health care
5providers to maintain records that document the medical care
6and services provided to recipients of Medical Assistance
7under this Article. Such records must be retained for a period
8of not less than 6 years from the date of service or as
9provided by applicable State law, whichever period is longer,
10except that if an audit is initiated within the required
11retention period then the records must be retained until the
12audit is completed and every exception is resolved. The
13Illinois Department shall require health care providers to
14make available, when authorized by the patient, in writing,
15the medical records in a timely fashion to other health care
16providers who are treating or serving persons eligible for
17Medical Assistance under this Article. All dispensers of
18medical services shall be required to maintain and retain
19business and professional records sufficient to fully and
20accurately document the nature, scope, details and receipt of
21the health care provided to persons eligible for medical
22assistance under this Code, in accordance with regulations
23promulgated by the Illinois Department. The rules and
24regulations shall require that proof of the receipt of
25prescription drugs, dentures, prosthetic devices and
26eyeglasses by eligible persons under this Section accompany

 

 

10300HB4180ham001- 31 -LRB103 34255 RPS 70122 a

1each claim for reimbursement submitted by the dispenser of
2such medical services. No such claims for reimbursement shall
3be approved for payment by the Illinois Department without
4such proof of receipt, unless the Illinois Department shall
5have put into effect and shall be operating a system of
6post-payment audit and review which shall, on a sampling
7basis, be deemed adequate by the Illinois Department to assure
8that such drugs, dentures, prosthetic devices and eyeglasses
9for which payment is being made are actually being received by
10eligible recipients. Within 90 days after September 16, 1984
11(the effective date of Public Act 83-1439), the Illinois
12Department shall establish a current list of acquisition costs
13for all prosthetic devices and any other items recognized as
14medical equipment and supplies reimbursable under this Article
15and shall update such list on a quarterly basis, except that
16the acquisition costs of all prescription drugs shall be
17updated no less frequently than every 30 days as required by
18Section 5-5.12.
19    Notwithstanding any other law to the contrary, the
20Illinois Department shall, within 365 days after July 22, 2013
21(the effective date of Public Act 98-104), establish
22procedures to permit skilled care facilities licensed under
23the Nursing Home Care Act to submit monthly billing claims for
24reimbursement purposes. Following development of these
25procedures, the Department shall, by July 1, 2016, test the
26viability of the new system and implement any necessary

 

 

10300HB4180ham001- 32 -LRB103 34255 RPS 70122 a

1operational or structural changes to its information
2technology platforms in order to allow for the direct
3acceptance and payment of nursing home claims.
4    Notwithstanding any other law to the contrary, the
5Illinois Department shall, within 365 days after August 15,
62014 (the effective date of Public Act 98-963), establish
7procedures to permit ID/DD facilities licensed under the ID/DD
8Community Care Act and MC/DD facilities licensed under the
9MC/DD Act to submit monthly billing claims for reimbursement
10purposes. Following development of these procedures, the
11Department shall have an additional 365 days to test the
12viability of the new system and to ensure that any necessary
13operational or structural changes to its information
14technology platforms are implemented.
15    The Illinois Department shall require all dispensers of
16medical services, other than an individual practitioner or
17group of practitioners, desiring to participate in the Medical
18Assistance program established under this Article to disclose
19all financial, beneficial, ownership, equity, surety or other
20interests in any and all firms, corporations, partnerships,
21associations, business enterprises, joint ventures, agencies,
22institutions or other legal entities providing any form of
23health care services in this State under this Article.
24    The Illinois Department may require that all dispensers of
25medical services desiring to participate in the medical
26assistance program established under this Article disclose,

 

 

10300HB4180ham001- 33 -LRB103 34255 RPS 70122 a

1under such terms and conditions as the Illinois Department may
2by rule establish, all inquiries from clients and attorneys
3regarding medical bills paid by the Illinois Department, which
4inquiries could indicate potential existence of claims or
5liens for the Illinois Department.
6    Enrollment of a vendor shall be subject to a provisional
7period and shall be conditional for one year. During the
8period of conditional enrollment, the Department may terminate
9the vendor's eligibility to participate in, or may disenroll
10the vendor from, the medical assistance program without cause.
11Unless otherwise specified, such termination of eligibility or
12disenrollment is not subject to the Department's hearing
13process. However, a disenrolled vendor may reapply without
14penalty.
15    The Department has the discretion to limit the conditional
16enrollment period for vendors based upon the category of risk
17of the vendor.
18    Prior to enrollment and during the conditional enrollment
19period in the medical assistance program, all vendors shall be
20subject to enhanced oversight, screening, and review based on
21the risk of fraud, waste, and abuse that is posed by the
22category of risk of the vendor. The Illinois Department shall
23establish the procedures for oversight, screening, and review,
24which may include, but need not be limited to: criminal and
25financial background checks; fingerprinting; license,
26certification, and authorization verifications; unscheduled or

 

 

10300HB4180ham001- 34 -LRB103 34255 RPS 70122 a

1unannounced site visits; database checks; prepayment audit
2reviews; audits; payment caps; payment suspensions; and other
3screening as required by federal or State law.
4    The Department shall define or specify the following: (i)
5by provider notice, the "category of risk of the vendor" for
6each type of vendor, which shall take into account the level of
7screening applicable to a particular category of vendor under
8federal law and regulations; (ii) by rule or provider notice,
9the maximum length of the conditional enrollment period for
10each category of risk of the vendor; and (iii) by rule, the
11hearing rights, if any, afforded to a vendor in each category
12of risk of the vendor that is terminated or disenrolled during
13the conditional enrollment period.
14    To be eligible for payment consideration, a vendor's
15payment claim or bill, either as an initial claim or as a
16resubmitted claim following prior rejection, must be received
17by the Illinois Department, or its fiscal intermediary, no
18later than 180 days after the latest date on the claim on which
19medical goods or services were provided, with the following
20exceptions:
21        (1) In the case of a provider whose enrollment is in
22    process by the Illinois Department, the 180-day period
23    shall not begin until the date on the written notice from
24    the Illinois Department that the provider enrollment is
25    complete.
26        (2) In the case of errors attributable to the Illinois

 

 

10300HB4180ham001- 35 -LRB103 34255 RPS 70122 a

1    Department or any of its claims processing intermediaries
2    which result in an inability to receive, process, or
3    adjudicate a claim, the 180-day period shall not begin
4    until the provider has been notified of the error.
5        (3) In the case of a provider for whom the Illinois
6    Department initiates the monthly billing process.
7        (4) In the case of a provider operated by a unit of
8    local government with a population exceeding 3,000,000
9    when local government funds finance federal participation
10    for claims payments.
11    For claims for services rendered during a period for which
12a recipient received retroactive eligibility, claims must be
13filed within 180 days after the Department determines the
14applicant is eligible. For claims for which the Illinois
15Department is not the primary payer, claims must be submitted
16to the Illinois Department within 180 days after the final
17adjudication by the primary payer.
18    In the case of long term care facilities, within 120
19calendar days of receipt by the facility of required
20prescreening information, new admissions with associated
21admission documents shall be submitted through the Medical
22Electronic Data Interchange (MEDI) or the Recipient
23Eligibility Verification (REV) System or shall be submitted
24directly to the Department of Human Services using required
25admission forms. Effective September 1, 2014, admission
26documents, including all prescreening information, must be

 

 

10300HB4180ham001- 36 -LRB103 34255 RPS 70122 a

1submitted through MEDI or REV. Confirmation numbers assigned
2to an accepted transaction shall be retained by a facility to
3verify timely submittal. Once an admission transaction has
4been completed, all resubmitted claims following prior
5rejection are subject to receipt no later than 180 days after
6the admission transaction has been completed.
7    Claims that are not submitted and received in compliance
8with the foregoing requirements shall not be eligible for
9payment under the medical assistance program, and the State
10shall have no liability for payment of those claims.
11    To the extent consistent with applicable information and
12privacy, security, and disclosure laws, State and federal
13agencies and departments shall provide the Illinois Department
14access to confidential and other information and data
15necessary to perform eligibility and payment verifications and
16other Illinois Department functions. This includes, but is not
17limited to: information pertaining to licensure;
18certification; earnings; immigration status; citizenship; wage
19reporting; unearned and earned income; pension income;
20employment; supplemental security income; social security
21numbers; National Provider Identifier (NPI) numbers; the
22National Practitioner Data Bank (NPDB); program and agency
23exclusions; taxpayer identification numbers; tax delinquency;
24corporate information; and death records.
25    The Illinois Department shall enter into agreements with
26State agencies and departments, and is authorized to enter

 

 

10300HB4180ham001- 37 -LRB103 34255 RPS 70122 a

1into agreements with federal agencies and departments, under
2which such agencies and departments shall share data necessary
3for medical assistance program integrity functions and
4oversight. The Illinois Department shall develop, in
5cooperation with other State departments and agencies, and in
6compliance with applicable federal laws and regulations,
7appropriate and effective methods to share such data. At a
8minimum, and to the extent necessary to provide data sharing,
9the Illinois Department shall enter into agreements with State
10agencies and departments, and is authorized to enter into
11agreements with federal agencies and departments, including,
12but not limited to: the Secretary of State; the Department of
13Revenue; the Department of Public Health; the Department of
14Human Services; and the Department of Financial and
15Professional Regulation.
16    Beginning in fiscal year 2013, the Illinois Department
17shall set forth a request for information to identify the
18benefits of a pre-payment, post-adjudication, and post-edit
19claims system with the goals of streamlining claims processing
20and provider reimbursement, reducing the number of pending or
21rejected claims, and helping to ensure a more transparent
22adjudication process through the utilization of: (i) provider
23data verification and provider screening technology; and (ii)
24clinical code editing; and (iii) pre-pay, pre-adjudicated, or
25post-adjudicated predictive modeling with an integrated case
26management system with link analysis. Such a request for

 

 

10300HB4180ham001- 38 -LRB103 34255 RPS 70122 a

1information shall not be considered as a request for proposal
2or as an obligation on the part of the Illinois Department to
3take any action or acquire any products or services.
4    The Illinois Department shall establish policies,
5procedures, standards and criteria by rule for the
6acquisition, repair and replacement of orthotic and prosthetic
7devices and durable medical equipment. Such rules shall
8provide, but not be limited to, the following services: (1)
9immediate repair or replacement of such devices by recipients;
10and (2) rental, lease, purchase or lease-purchase of durable
11medical equipment in a cost-effective manner, taking into
12consideration the recipient's medical prognosis, the extent of
13the recipient's needs, and the requirements and costs for
14maintaining such equipment. Subject to prior approval, such
15rules shall enable a recipient to temporarily acquire and use
16alternative or substitute devices or equipment pending repairs
17or replacements of any device or equipment previously
18authorized for such recipient by the Department.
19Notwithstanding any provision of Section 5-5f to the contrary,
20the Department may, by rule, exempt certain replacement
21wheelchair parts from prior approval and, for wheelchairs,
22wheelchair parts, wheelchair accessories, and related seating
23and positioning items, determine the wholesale price by
24methods other than actual acquisition costs.
25    The Department shall require, by rule, all providers of
26durable medical equipment to be accredited by an accreditation

 

 

10300HB4180ham001- 39 -LRB103 34255 RPS 70122 a

1organization approved by the federal Centers for Medicare and
2Medicaid Services and recognized by the Department in order to
3bill the Department for providing durable medical equipment to
4recipients. No later than 15 months after the effective date
5of the rule adopted pursuant to this paragraph, all providers
6must meet the accreditation requirement.
7    In order to promote environmental responsibility, meet the
8needs of recipients and enrollees, and achieve significant
9cost savings, the Department, or a managed care organization
10under contract with the Department, may provide recipients or
11managed care enrollees who have a prescription or Certificate
12of Medical Necessity access to refurbished durable medical
13equipment under this Section (excluding prosthetic and
14orthotic devices as defined in the Orthotics, Prosthetics, and
15Pedorthics Practice Act and complex rehabilitation technology
16products and associated services) through the State's
17assistive technology program's reutilization program, using
18staff with the Assistive Technology Professional (ATP)
19Certification if the refurbished durable medical equipment:
20(i) is available; (ii) is less expensive, including shipping
21costs, than new durable medical equipment of the same type;
22(iii) is able to withstand at least 3 years of use; (iv) is
23cleaned, disinfected, sterilized, and safe in accordance with
24federal Food and Drug Administration regulations and guidance
25governing the reprocessing of medical devices in health care
26settings; and (v) equally meets the needs of the recipient or

 

 

10300HB4180ham001- 40 -LRB103 34255 RPS 70122 a

1enrollee. The reutilization program shall confirm that the
2recipient or enrollee is not already in receipt of the same or
3similar equipment from another service provider, and that the
4refurbished durable medical equipment equally meets the needs
5of the recipient or enrollee. Nothing in this paragraph shall
6be construed to limit recipient or enrollee choice to obtain
7new durable medical equipment or place any additional prior
8authorization conditions on enrollees of managed care
9organizations.
10    The Department shall execute, relative to the nursing home
11prescreening project, written inter-agency agreements with the
12Department of Human Services and the Department on Aging, to
13effect the following: (i) intake procedures and common
14eligibility criteria for those persons who are receiving
15non-institutional services; and (ii) the establishment and
16development of non-institutional services in areas of the
17State where they are not currently available or are
18undeveloped; and (iii) notwithstanding any other provision of
19law, subject to federal approval, on and after July 1, 2012, an
20increase in the determination of need (DON) scores from 29 to
2137 for applicants for institutional and home and
22community-based long term care; if and only if federal
23approval is not granted, the Department may, in conjunction
24with other affected agencies, implement utilization controls
25or changes in benefit packages to effectuate a similar savings
26amount for this population; and (iv) no later than July 1,

 

 

10300HB4180ham001- 41 -LRB103 34255 RPS 70122 a

12013, minimum level of care eligibility criteria for
2institutional and home and community-based long term care; and
3(v) no later than October 1, 2013, establish procedures to
4permit long term care providers access to eligibility scores
5for individuals with an admission date who are seeking or
6receiving services from the long term care provider. In order
7to select the minimum level of care eligibility criteria, the
8Governor shall establish a workgroup that includes affected
9agency representatives and stakeholders representing the
10institutional and home and community-based long term care
11interests. This Section shall not restrict the Department from
12implementing lower level of care eligibility criteria for
13community-based services in circumstances where federal
14approval has been granted.
15    The Illinois Department shall develop and operate, in
16cooperation with other State Departments and agencies and in
17compliance with applicable federal laws and regulations,
18appropriate and effective systems of health care evaluation
19and programs for monitoring of utilization of health care
20services and facilities, as it affects persons eligible for
21medical assistance under this Code.
22    The Illinois Department shall report annually to the
23General Assembly, no later than the second Friday in April of
241979 and each year thereafter, in regard to:
25        (a) actual statistics and trends in utilization of
26    medical services by public aid recipients;

 

 

10300HB4180ham001- 42 -LRB103 34255 RPS 70122 a

1        (b) actual statistics and trends in the provision of
2    the various medical services by medical vendors;
3        (c) current rate structures and proposed changes in
4    those rate structures for the various medical vendors; and
5        (d) efforts at utilization review and control by the
6    Illinois Department.
7    The period covered by each report shall be the 3 years
8ending on the June 30 prior to the report. The report shall
9include suggested legislation for consideration by the General
10Assembly. The requirement for reporting to the General
11Assembly shall be satisfied by filing copies of the report as
12required by Section 3.1 of the General Assembly Organization
13Act, and filing such additional copies with the State
14Government Report Distribution Center for the General Assembly
15as is required under paragraph (t) of Section 7 of the State
16Library Act.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23    On and after July 1, 2012, the Department shall reduce any
24rate of reimbursement for services or other payments or alter
25any methodologies authorized by this Code to reduce any rate
26of reimbursement for services or other payments in accordance

 

 

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1with Section 5-5e.
2    Because kidney transplantation can be an appropriate,
3cost-effective alternative to renal dialysis when medically
4necessary and notwithstanding the provisions of Section 1-11
5of this Code, beginning October 1, 2014, the Department shall
6cover kidney transplantation for noncitizens with end-stage
7renal disease who are not eligible for comprehensive medical
8benefits, who meet the residency requirements of Section 5-3
9of this Code, and who would otherwise meet the financial
10requirements of the appropriate class of eligible persons
11under Section 5-2 of this Code. To qualify for coverage of
12kidney transplantation, such person must be receiving
13emergency renal dialysis services covered by the Department.
14Providers under this Section shall be prior approved and
15certified by the Department to perform kidney transplantation
16and the services under this Section shall be limited to
17services associated with kidney transplantation.
18    Notwithstanding any other provision of this Code to the
19contrary, on or after July 1, 2015, all FDA approved forms of
20medication assisted treatment prescribed for the treatment of
21alcohol dependence or treatment of opioid dependence shall be
22covered under both fee-for-service fee for service and managed
23care medical assistance programs for persons who are otherwise
24eligible for medical assistance under this Article and shall
25not be subject to any (1) utilization control, other than
26those established under the American Society of Addiction

 

 

10300HB4180ham001- 44 -LRB103 34255 RPS 70122 a

1Medicine patient placement criteria, (2) prior authorization
2mandate, or (3) lifetime restriction limit mandate.
3    On or after July 1, 2015, opioid antagonists prescribed
4for the treatment of an opioid overdose, including the
5medication product, administration devices, and any pharmacy
6fees or hospital fees related to the dispensing, distribution,
7and administration of the opioid antagonist, shall be covered
8under the medical assistance program for persons who are
9otherwise eligible for medical assistance under this Article.
10As used in this Section, "opioid antagonist" means a drug that
11binds to opioid receptors and blocks or inhibits the effect of
12opioids acting on those receptors, including, but not limited
13to, naloxone hydrochloride or any other similarly acting drug
14approved by the U.S. Food and Drug Administration. The
15Department shall not impose a copayment on the coverage
16provided for naloxone hydrochloride under the medical
17assistance program.
18    Upon federal approval, the Department shall provide
19coverage and reimbursement for all drugs that are approved for
20marketing by the federal Food and Drug Administration and that
21are recommended by the federal Public Health Service or the
22United States Centers for Disease Control and Prevention for
23pre-exposure prophylaxis and related pre-exposure prophylaxis
24services, including, but not limited to, HIV and sexually
25transmitted infection screening, treatment for sexually
26transmitted infections, medical monitoring, assorted labs, and

 

 

10300HB4180ham001- 45 -LRB103 34255 RPS 70122 a

1counseling to reduce the likelihood of HIV infection among
2individuals who are not infected with HIV but who are at high
3risk of HIV infection.
4    A federally qualified health center, as defined in Section
51905(l)(2)(B) of the federal Social Security Act, shall be
6reimbursed by the Department in accordance with the federally
7qualified health center's encounter rate for services provided
8to medical assistance recipients that are performed by a
9dental hygienist, as defined under the Illinois Dental
10Practice Act, working under the general supervision of a
11dentist and employed by a federally qualified health center.
12    Within 90 days after October 8, 2021 (the effective date
13of Public Act 102-665), the Department shall seek federal
14approval of a State Plan amendment to expand coverage for
15family planning services that includes presumptive eligibility
16to individuals whose income is at or below 208% of the federal
17poverty level. Coverage under this Section shall be effective
18beginning no later than December 1, 2022.
19    Subject to approval by the federal Centers for Medicare
20and Medicaid Services of a Title XIX State Plan amendment
21electing the Program of All-Inclusive Care for the Elderly
22(PACE) as a State Medicaid option, as provided for by Subtitle
23I (commencing with Section 4801) of Title IV of the Balanced
24Budget Act of 1997 (Public Law 105-33) and Part 460
25(commencing with Section 460.2) of Subchapter E of Title 42 of
26the Code of Federal Regulations, PACE program services shall

 

 

10300HB4180ham001- 46 -LRB103 34255 RPS 70122 a

1become a covered benefit of the medical assistance program,
2subject to criteria established in accordance with all
3applicable laws.
4    Notwithstanding any other provision of this Code,
5community-based pediatric palliative care from a trained
6interdisciplinary team shall be covered under the medical
7assistance program as provided in Section 15 of the Pediatric
8Palliative Care Act.
9    Notwithstanding any other provision of this Code, within
1012 months after June 2, 2022 (the effective date of Public Act
11102-1037) and subject to federal approval, acupuncture
12services performed by an acupuncturist licensed under the
13Acupuncture Practice Act who is acting within the scope of his
14or her license shall be covered under the medical assistance
15program. The Department shall apply for any federal waiver or
16State Plan amendment, if required, to implement this
17paragraph. The Department may adopt any rules, including
18standards and criteria, necessary to implement this paragraph.
19    Notwithstanding any other provision of this Code, the
20medical assistance program shall, subject to appropriation and
21federal approval, reimburse hospitals for costs associated
22with a newborn screening test for the presence of
23metachromatic leukodystrophy, as required under the Newborn
24Metabolic Screening Act, at a rate not less than the fee
25charged by the Department of Public Health. The Department
26shall seek federal approval before the implementation of the

 

 

10300HB4180ham001- 47 -LRB103 34255 RPS 70122 a

1newborn screening test fees by the Department of Public
2Health.
3    Notwithstanding any other provision of this Code,
4beginning on January 1, 2024, subject to federal approval,
5cognitive assessment and care planning services provided to a
6person who experiences signs or symptoms of cognitive
7impairment, as defined by the Diagnostic and Statistical
8Manual of Mental Disorders, Fifth Edition, shall be covered
9under the medical assistance program for persons who are
10otherwise eligible for medical assistance under this Article.
11    Notwithstanding any other provision of this Code,
12medically necessary reconstructive services that are intended
13to restore physical appearance shall be covered under the
14medical assistance program for persons who are otherwise
15eligible for medical assistance under this Article. As used in
16this paragraph, "reconstructive services" means treatments
17performed on structures of the body damaged by trauma to
18restore physical appearance.
19(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
20102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2155, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
22eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
23102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
245-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
25102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
261-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;

 

 

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1103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
21-1-24; revised 12-15-23.)
 
3    Section 99. Effective date. This Act takes effect January
41, 2026.".