Rep. Nabeela Syed

Filed: 3/20/2024

 

 


 

 


 
10300HB4180ham002LRB103 34255 RPS 70899 a

1
AMENDMENT TO HOUSE BILL 4180

2    AMENDMENT NO. ______. Amend House Bill 4180, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Counties Code is amended by changing
6Section 5-1069 as follows:
 
7    (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
8    Sec. 5-1069. Group life, health, accident, hospital, and
9medical insurance.
10    (a) The county board of any county may arrange to provide,
11for the benefit of employees of the county, group life,
12health, accident, hospital, and medical insurance, or any one
13or any combination of those types of insurance, or the county
14board may self-insure, for the benefit of its employees, all
15or a portion of the employees' group life, health, accident,
16hospital, and medical insurance, or any one or any combination

 

 

10300HB4180ham002- 2 -LRB103 34255 RPS 70899 a

1of those types of insurance, including a combination of
2self-insurance and other types of insurance authorized by this
3Section, provided that the county board complies with all
4other requirements of this Section. The insurance may include
5provision for employees who rely on treatment by prayer or
6spiritual means alone for healing in accordance with the
7tenets and practice of a well recognized religious
8denomination. The county board may provide for payment by the
9county of a portion or all of the premium or charge for the
10insurance with the employee paying the balance of the premium
11or charge, if any. If the county board undertakes a plan under
12which the county pays only a portion of the premium or charge,
13the county board shall provide for withholding and deducting
14from the compensation of those employees who consent to join
15the plan the balance of the premium or charge for the
16insurance.
17    (b) If the county board does not provide for
18self-insurance or for a plan under which the county pays a
19portion or all of the premium or charge for a group insurance
20plan, the county board may provide for withholding and
21deducting from the compensation of those employees who consent
22thereto the total premium or charge for any group life,
23health, accident, hospital, and medical insurance.
24    (c) The county board may exercise the powers granted in
25this Section only if it provides for self-insurance or, where
26it makes arrangements to provide group insurance through an

 

 

10300HB4180ham002- 3 -LRB103 34255 RPS 70899 a

1insurance carrier, if the kinds of group insurance are
2obtained from an insurance company authorized to do business
3in the State of Illinois. The county board may enact an
4ordinance prescribing the method of operation of the insurance
5program.
6    (d) If a county, including a home rule county, is a
7self-insurer for purposes of providing health insurance
8coverage for its employees, the insurance coverage shall
9include screening by low-dose mammography for all patients
10women 35 years of age or older for the presence of occult
11breast cancer unless the county elects to provide mammograms
12itself under Section 5-1069.1. The coverage shall be as
13follows:
14        (1) A baseline mammogram for patients women 35 to 39
15    years of age.
16        (2) An annual mammogram for patients women 40 years of
17    age or older.
18        (3) A mammogram at the age and intervals considered
19    medically necessary by the patient's woman's health care
20    provider for patients women under 40 years of age and
21    having a family history of breast cancer, prior personal
22    history of breast cancer, positive genetic testing, or
23    other risk factors.
24        (4) For a group policy of accident and health
25    insurance that is amended, delivered, issued, or renewed
26    on or after January 1, 2020 (the effective date of Public

 

 

10300HB4180ham002- 4 -LRB103 34255 RPS 70899 a

1    Act 101-580) this amendatory Act of the 101st General
2    Assembly, a comprehensive ultrasound screening of an
3    entire breast or breasts if a mammogram demonstrates
4    heterogeneous or dense breast tissue or when medically
5    necessary as determined by a physician licensed to
6    practice medicine in all of its branches, advanced
7    practice registered nurse, or physician assistant.
8        (4.5) For a group policy of accident and health
9    insurance that is amended, delivered, issued, or renewed
10    on or after the effective date of this amendatory Act of
11    the 103rd General Assembly, molecular breast imaging (MBI)
12    and magnetic resonance imaging of an entire breast or
13    breasts if a mammogram demonstrates heterogeneous or dense
14    breast tissue or when medically necessary as determined by
15    a physician licensed to practice medicine in all of its
16    branches, advanced practice registered nurse, or physician
17    assistant.
18        (5) For a group policy of accident and health
19    insurance that is amended, delivered, issued, or renewed
20    on or after January 1, 2020 (the effective date of Public
21    Act 101-580) this amendatory Act of the 101st General
22    Assembly, a diagnostic mammogram when medically necessary,
23    as determined by a physician licensed to practice medicine
24    in all its branches, advanced practice registered nurse,
25    or physician assistant.
26    A policy subject to this subsection shall not impose a

 

 

10300HB4180ham002- 5 -LRB103 34255 RPS 70899 a

1deductible, coinsurance, copayment, or any other cost-sharing
2requirement on the coverage provided; except that this
3sentence does not apply to coverage of diagnostic mammograms
4to the extent such coverage would disqualify a high-deductible
5health plan from eligibility for a health savings account
6pursuant to Section 223 of the Internal Revenue Code (26
7U.S.C. 223).
8    For purposes of this subsection:
9    "Diagnostic mammogram" means a mammogram obtained using
10diagnostic mammography.
11    "Diagnostic mammography" means a method of screening that
12is designed to evaluate an abnormality in a breast, including
13an abnormality seen or suspected on a screening mammogram or a
14subjective or objective abnormality otherwise detected in the
15breast.
16    "Low-dose mammography" means the x-ray examination of the
17breast using equipment dedicated specifically for mammography,
18including the x-ray tube, filter, compression device, and
19image receptor, with an average radiation exposure delivery of
20less than one rad per breast for 2 views of an average size
21breast. The term also includes digital mammography.
22    (d-5) Coverage as described by subsection (d) shall be
23provided at no cost to the insured and shall not be applied to
24an annual or lifetime maximum benefit.
25    (d-10) When health care services are available through
26contracted providers and a person does not comply with plan

 

 

10300HB4180ham002- 6 -LRB103 34255 RPS 70899 a

1provisions specific to the use of contracted providers, the
2requirements of subsection (d-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    (d-15) If a county, including a home rule county, is a
10self-insurer for purposes of providing health insurance
11coverage for its employees, the insurance coverage shall
12include mastectomy coverage, which includes coverage for
13prosthetic devices or reconstructive surgery incident to the
14mastectomy. Coverage for breast reconstruction in connection
15with a mastectomy shall 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

 

 

10300HB4180ham002- 7 -LRB103 34255 RPS 70899 a

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    A county, including a home rule county, that is a
10self-insurer for purposes of providing health insurance
11coverage for its employees, may not penalize or reduce or
12limit the reimbursement of an attending provider or provide
13incentives (monetary or otherwise) to an attending provider to
14induce the provider to provide care to an insured in a manner
15inconsistent with this Section.
16    (d-20) The requirement that mammograms be included in
17health insurance coverage as provided in subsections (d)
18through (d-15) is an exclusive power and function of the State
19and is a denial and limitation under Article VII, Section 6,
20subsection (h) of the Illinois Constitution of home rule
21county powers. A home rule county to which subsections (d)
22through (d-15) apply must comply with every provision of those
23subsections.
24    (e) The term "employees" as used in this Section includes
25elected or appointed officials but does not include temporary
26employees.

 

 

10300HB4180ham002- 8 -LRB103 34255 RPS 70899 a

1    (f) The county board may, by ordinance, arrange to provide
2group life, health, accident, hospital, and medical insurance,
3or any one or a combination of those types of insurance, under
4this Section to retired former employees and retired former
5elected or appointed officials of the county.
6    (g) Rulemaking authority to implement this amendatory Act
7of the 95th General Assembly, if any, is conditioned on the
8rules being adopted in accordance with all provisions of the
9Illinois Administrative Procedure Act and all rules and
10procedures of the Joint Committee on Administrative Rules; any
11purported rule not so adopted, for whatever reason, is
12unauthorized.
13(Source: P.A. 100-513, eff. 1-1-18; 101-580, eff. 1-1-20.)
 
14    Section 10. The Illinois Municipal Code is amended by
15changing Section 10-4-2 as follows:
 
16    (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
17    Sec. 10-4-2. Group insurance.
18    (a) The corporate authorities of any municipality may
19arrange to provide, for the benefit of employees of the
20municipality, group life, health, accident, hospital, and
21medical insurance, or any one or any combination of those
22types of insurance, and may arrange to provide that insurance
23for the benefit of the spouses or dependents of those
24employees. The insurance may include provision for employees

 

 

10300HB4180ham002- 9 -LRB103 34255 RPS 70899 a

1or other insured persons who rely on treatment by prayer or
2spiritual means alone for healing in accordance with the
3tenets and practice of a well recognized religious
4denomination. The corporate authorities may provide for
5payment by the municipality of a portion of the premium or
6charge for the insurance with the employee paying the balance
7of the premium or charge. If the corporate authorities
8undertake a plan under which the municipality pays a portion
9of the premium or charge, the corporate authorities shall
10provide for withholding and deducting from the compensation of
11those municipal employees who consent to join the plan the
12balance of the premium or charge for the insurance.
13    (b) If the corporate authorities do not provide for a plan
14under which the municipality pays a portion of the premium or
15charge for a group insurance plan, the corporate authorities
16may provide for withholding and deducting from the
17compensation of those employees who consent thereto the
18premium or charge for any group life, health, accident,
19hospital, and medical insurance.
20    (c) The corporate authorities may exercise the powers
21granted in this Section only if the kinds of group insurance
22are obtained from an insurance company authorized to do
23business in the State of Illinois, or are obtained through an
24intergovernmental joint self-insurance pool as authorized
25under the Intergovernmental Cooperation Act. The corporate
26authorities may enact an ordinance prescribing the method of

 

 

10300HB4180ham002- 10 -LRB103 34255 RPS 70899 a

1operation of the insurance program.
2    (d) If a municipality, including a home rule municipality,
3is a self-insurer for purposes of providing health insurance
4coverage for its employees, the insurance coverage shall
5include screening by low-dose mammography for all patients
6women 35 years of age or older for the presence of occult
7breast cancer unless the municipality elects to provide
8mammograms itself under Section 10-4-2.1. The coverage shall
9be as follows:
10        (1) A baseline mammogram for patients women 35 to 39
11    years of age.
12        (2) An annual mammogram for patients women 40 years of
13    age or older.
14        (3) A mammogram at the age and intervals considered
15    medically necessary by the patient's woman's health care
16    provider for patients women under 40 years of age and
17    having a family history of breast cancer, prior personal
18    history of breast cancer, positive genetic testing, or
19    other risk factors.
20        (4) For a group policy of accident and health
21    insurance that is amended, delivered, issued, or renewed
22    on or after January 1, 2020 (the effective date of Public
23    Act 101-580) this amendatory Act of the 101st General
24    Assembly, a comprehensive ultrasound screening of an
25    entire breast or breasts if a mammogram demonstrates
26    heterogeneous or dense breast tissue or when medically

 

 

10300HB4180ham002- 11 -LRB103 34255 RPS 70899 a

1    necessary as determined by a physician licensed to
2    practice medicine in all of its branches.
3        (4.5) For a group policy of accident and health
4    insurance that is amended, delivered, issued, or renewed
5    on or after the effective date of this amendatory Act of
6    the 103rd General Assembly, molecular breast imaging (MBI)
7    and magnetic resonance imaging of an entire breast or
8    breasts if a mammogram demonstrates heterogeneous or dense
9    breast tissue or when medically necessary as determined by
10    a physician licensed to practice medicine in all of its
11    branches, advanced practice registered nurse, or physician
12    assistant.
13        (5) For a group policy of accident and health
14    insurance that is amended, delivered, issued, or renewed
15    on or after January 1, 2020, (the effective date of Public
16    Act 101-580) this amendatory Act of the 101st General
17    Assembly, a diagnostic mammogram when medically necessary,
18    as determined by a physician licensed to practice medicine
19    in all its branches, advanced practice registered nurse,
20    or physician assistant.
21    A policy subject to this subsection shall not impose a
22deductible, coinsurance, copayment, or any other cost-sharing
23requirement on the coverage provided; except that this
24sentence does not apply to coverage of diagnostic mammograms
25to the extent such coverage would disqualify a high-deductible
26health plan from eligibility for a health savings account

 

 

10300HB4180ham002- 12 -LRB103 34255 RPS 70899 a

1pursuant to Section 223 of the Internal Revenue Code (26
2U.S.C. 223).
3    For purposes of this subsection:
4    "Diagnostic mammogram" means a mammogram obtained using
5diagnostic mammography.
6    "Diagnostic mammography" means a method of screening that
7is designed to evaluate an abnormality in a breast, including
8an abnormality seen or suspected on a screening mammogram or a
9subjective or objective abnormality otherwise detected in the
10breast.
11    "Low-dose mammography" means the x-ray examination of the
12breast using equipment dedicated specifically for mammography,
13including the x-ray tube, filter, compression device, and
14image receptor, with an average radiation exposure delivery of
15less than one rad per breast for 2 views of an average size
16breast. The term also includes digital mammography.
17    (d-5) Coverage as described by subsection (d) shall be
18provided at no cost to the insured and shall not be applied to
19an annual or lifetime maximum benefit.
20    (d-10) When health care services are available through
21contracted providers and a person does not comply with plan
22provisions specific to the use of contracted providers, the
23requirements of subsection (d-5) are not applicable. When a
24person does not comply with plan provisions specific to the
25use of contracted providers, plan provisions specific to the
26use of non-contracted providers must be applied without

 

 

10300HB4180ham002- 13 -LRB103 34255 RPS 70899 a

1distinction for coverage required by this Section and shall be
2at least as favorable as for other radiological examinations
3covered by the policy or contract.
4    (d-15) If a municipality, including a home rule
5municipality, is a self-insurer for purposes of providing
6health insurance coverage for its employees, the insurance
7coverage shall include mastectomy coverage, which includes
8coverage for prosthetic devices or reconstructive surgery
9incident to the mastectomy. Coverage for breast reconstruction
10in connection with a mastectomy shall include:
11        (1) reconstruction of the breast upon which the
12    mastectomy has been performed;
13        (2) surgery and reconstruction of the other breast to
14    produce a symmetrical appearance; and
15        (3) prostheses and treatment for physical
16    complications at all stages of mastectomy, including
17    lymphedemas.
18Care shall be determined in consultation with the attending
19physician and the patient. The offered coverage for prosthetic
20devices and reconstructive surgery shall be subject to the
21deductible and coinsurance conditions applied to the
22mastectomy, and all other terms and conditions applicable to
23other benefits. When a mastectomy is performed and there is no
24evidence of malignancy then the offered coverage may be
25limited to the provision of prosthetic devices and
26reconstructive surgery to within 2 years after the date of the

 

 

10300HB4180ham002- 14 -LRB103 34255 RPS 70899 a

1mastectomy. As used in this Section, "mastectomy" means the
2removal of all or part of the breast for medically necessary
3reasons, as determined by a licensed physician.
4    A municipality, including a home rule municipality, that
5is a self-insurer for purposes of providing health insurance
6coverage for its employees, may not penalize or reduce or
7limit the reimbursement of an attending provider or provide
8incentives (monetary or otherwise) to an attending provider to
9induce the provider to provide care to an insured in a manner
10inconsistent with this Section.
11    (d-20) The requirement that mammograms be included in
12health insurance coverage as provided in subsections (d)
13through (d-15) is an exclusive power and function of the State
14and is a denial and limitation under Article VII, Section 6,
15subsection (h) of the Illinois Constitution of home rule
16municipality powers. A home rule municipality to which
17subsections (d) through (d-15) apply must comply with every
18provision of those subsections.
19    (e) 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. 100-863, eff. 8-14-18; 101-580, eff. 1-1-20.)
 

 

 

10300HB4180ham002- 15 -LRB103 34255 RPS 70899 a

1    Section 15. The Illinois Insurance Code is amended by
2changing Section 356g as follows:
 
3    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
4    Sec. 356g. Mammograms; mastectomies.
5    (a) Every insurer shall provide in each group or
6individual policy, contract, or certificate of insurance
7issued or renewed for persons who are residents of this State,
8coverage for screening by low-dose mammography for all
9patients women 35 years of age or older for the presence of
10occult breast cancer within the provisions of the policy,
11contract, or certificate. The coverage shall be as follows:
12         (1) A baseline mammogram for patients women 35 to 39
13    years of age.
14         (2) An annual mammogram for patients women 40 years
15    of age or older.
16         (3) A mammogram at the age and intervals considered
17    medically necessary by the patient's woman's health care
18    provider for patients women under 40 years of age and
19    having a family history of breast cancer, prior personal
20    history of breast cancer, positive genetic testing, or
21    other risk factors.
22        (4) 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

 

 

10300HB4180ham002- 16 -LRB103 34255 RPS 70899 a

1    Act of the 101st General Assembly, a comprehensive
2    ultrasound screening and MRI of an entire breast or
3    breasts if a mammogram demonstrates heterogeneous or dense
4    breast tissue or when medically necessary as determined by
5    a physician licensed to practice medicine in all of its
6    branches.
7        (4.5) For a group policy of accident and health
8    insurance that is amended, delivered, issued, or renewed
9    on or after the effective date of this amendatory Act of
10    the 103rd General Assembly, molecular breast imaging (MBI)
11    of an entire breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue or when medically
13    necessary as determined by a physician licensed to
14    practice medicine in all of its branches, advanced
15    practice registered nurse, or physician assistant.
16        (5) A screening MRI when medically necessary, as
17    determined by a physician licensed to practice medicine in
18    all of its branches.
19        (6) For an individual or group policy of accident and
20    health insurance or a managed care plan that is amended,
21    delivered, issued, or renewed on or after January 1, 2020
22    (the effective date of Public Act 101-580) this amendatory
23    Act of the 101st General Assembly, a diagnostic mammogram
24    when medically necessary, as determined by a physician
25    licensed to practice medicine in all its branches,
26    advanced practice registered nurse, or physician

 

 

10300HB4180ham002- 17 -LRB103 34255 RPS 70899 a

1    assistant.
2    A policy subject to this subsection shall not impose a
3deductible, coinsurance, copayment, or any other cost-sharing
4requirement on the coverage provided; except that this
5sentence does not apply to coverage of diagnostic mammograms
6to the extent such coverage would disqualify a high-deductible
7health plan from eligibility for a health savings account
8pursuant to Section 223 of the Internal Revenue Code (26
9U.S.C. 223).
10    For purposes of this Section:
11    "Diagnostic mammogram" means a mammogram obtained using
12diagnostic mammography.
13    "Diagnostic mammography" means a method of screening that
14is designed to evaluate an abnormality in a breast, including
15an abnormality seen or suspected on a screening mammogram or a
16subjective or objective abnormality otherwise detected in the
17breast.
18    "Low-dose mammography" means the x-ray examination of the
19breast using equipment dedicated specifically for mammography,
20including the x-ray tube, filter, compression device, and
21image receptor, with radiation exposure delivery of less than
221 rad per breast for 2 views of an average size breast. The
23term also includes digital mammography and includes breast
24tomosynthesis. As used in this Section, the term "breast
25tomosynthesis" means a radiologic procedure that involves the
26acquisition of projection images over the stationary breast to

 

 

10300HB4180ham002- 18 -LRB103 34255 RPS 70899 a

1produce cross-sectional digital three-dimensional images of
2the breast.
3    If, at any time, the Secretary of the United States
4Department of Health and Human Services, or its successor
5agency, promulgates rules or regulations to be published in
6the Federal Register or publishes a comment in the Federal
7Register or issues an opinion, guidance, or other action that
8would require the State, pursuant to any provision of the
9Patient Protection and Affordable Care Act (Public Law
10111-148), including, but not limited to, 42 U.S.C.
1118031(d)(3)(B) or any successor provision, to defray the cost
12of any coverage for breast tomosynthesis outlined in this
13subsection, then the requirement that an insurer cover breast
14tomosynthesis is inoperative other than any such coverage
15authorized under Section 1902 of the Social Security Act, 42
16U.S.C. 1396a, and the State shall not assume any obligation
17for the cost of coverage for breast tomosynthesis set forth in
18this subsection.
19    (a-5) Coverage as described by subsection (a) shall be
20provided at no cost to the insured and shall not be applied to
21an annual or lifetime maximum benefit.
22    (a-10) When health care services are available through
23contracted providers and a person does not comply with plan
24provisions specific to the use of contracted providers, the
25requirements of subsection (a-5) are not applicable. When a
26person does not comply with plan provisions specific to the

 

 

10300HB4180ham002- 19 -LRB103 34255 RPS 70899 a

1use of contracted providers, plan provisions specific to the
2use of non-contracted providers must be applied without
3distinction for coverage required by this Section and shall be
4at least as favorable as for other radiological examinations
5covered by the policy or contract.
6    (b) No policy of accident or health insurance that
7provides for the surgical procedure known as a mastectomy
8shall be issued, amended, delivered, or renewed in this State
9unless that coverage also provides for prosthetic devices or
10reconstructive surgery incident to the mastectomy. Coverage
11for breast reconstruction in connection with a mastectomy
12shall include:
13        (1) reconstruction of the breast upon which the
14    mastectomy has been performed;
15        (2) surgery and reconstruction of the other breast to
16    produce a symmetrical appearance; and
17        (3) prostheses and treatment for physical
18    complications at all stages of mastectomy, including
19    lymphedemas.
20Care shall be determined in consultation with the attending
21physician and the patient. The offered coverage for prosthetic
22devices and reconstructive surgery shall be subject to the
23deductible and coinsurance conditions applied to the
24mastectomy, and all other terms and conditions applicable to
25other benefits. When a mastectomy is performed and there is no
26evidence of malignancy then the offered coverage may be

 

 

10300HB4180ham002- 20 -LRB103 34255 RPS 70899 a

1limited to the provision of prosthetic devices and
2reconstructive surgery to within 2 years after the date of the
3mastectomy. As used in this Section, "mastectomy" means the
4removal of all or part of the breast for medically necessary
5reasons, as determined by a licensed physician.
6    Written notice of the availability of coverage under this
7Section shall be delivered to the insured upon enrollment and
8annually thereafter. An insurer may not deny to an insured
9eligibility, or continued eligibility, to enroll or to renew
10coverage under the terms of the plan solely for the purpose of
11avoiding the requirements of this Section. An insurer may not
12penalize or reduce or limit the reimbursement of an attending
13provider or provide incentives (monetary or otherwise) to an
14attending provider to induce the provider to provide care to
15an insured in a manner inconsistent with this Section.
16    (c) Rulemaking authority to implement Public Act 95-1045,
17if any, is conditioned on the rules being adopted in
18accordance with all provisions of the Illinois Administrative
19Procedure Act and all rules and procedures of the Joint
20Committee on Administrative Rules; any purported rule not so
21adopted, for whatever reason, is unauthorized.
22(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
 
23    Section 20. The Health Maintenance Organization Act is
24amended by changing Sections 4-6.1 and 5-3 as follows:
 

 

 

10300HB4180ham002- 21 -LRB103 34255 RPS 70899 a

1    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
2    Sec. 4-6.1. Mammograms; mastectomies.
3    (a) Every contract or evidence of coverage issued by a
4Health Maintenance Organization for persons who are residents
5of this State shall contain coverage for screening by low-dose
6mammography for all patients women 35 years of age or older for
7the presence of occult breast cancer. The coverage shall be as
8follows:
9        (1) A baseline mammogram for patients women 35 to 39
10    years of age.
11        (2) An annual mammogram for patients women 40 years of
12    age or older.
13        (3) A mammogram at the age and intervals considered
14    medically necessary by the patient's woman's health care
15    provider for patients women under 40 years of age and
16    having a family history of breast cancer, prior personal
17    history of breast cancer, positive genetic testing, or
18    other risk factors.
19        (4) For an individual or group policy of accident and
20    health insurance or a managed care plan that is amended,
21    delivered, issued, or renewed on or after January 1, 2020
22    (the effective date of Public Act 101-580) this amendatory
23    Act of the 101st General Assembly, a comprehensive
24    ultrasound screening and MRI of an entire breast or
25    breasts if a mammogram demonstrates heterogeneous or dense
26    breast tissue or when medically necessary as determined by

 

 

10300HB4180ham002- 22 -LRB103 34255 RPS 70899 a

1    a physician licensed to practice medicine in all of its
2    branches.
3        (4.5) For a group policy of accident and health
4    insurance that is amended, delivered, issued, or renewed
5    on or after the effective date of this amendatory Act of
6    the 103rd General Assembly, molecular breast imaging (MBI)
7    of an entire breast or breasts if a mammogram demonstrates
8    heterogeneous or dense breast tissue or when medically
9    necessary as determined by a physician licensed to
10    practice medicine in all of its branches, advanced
11    practice registered nurse, or physician assistant.
12        (5) For an individual or group policy of accident and
13    health insurance or a managed care plan that is amended,
14    delivered, issued, or renewed on or after January 1, 2020
15    (the effective date of Public Act 101-580) this amendatory
16    Act of the 101st General Assembly, a diagnostic mammogram
17    when medically necessary, as determined by a physician
18    licensed to practice medicine in all its branches,
19    advanced practice registered nurse, or physician
20    assistant.
21    A policy subject to this subsection shall not impose a
22deductible, coinsurance, copayment, or any other cost-sharing
23requirement on the coverage provided; except that this
24sentence does not apply to coverage of diagnostic mammograms
25to the extent such coverage would disqualify a high-deductible
26health plan from eligibility for a health savings account

 

 

10300HB4180ham002- 23 -LRB103 34255 RPS 70899 a

1pursuant to Section 223 of the Internal Revenue Code (26
2U.S.C. 223).
3    For purposes of this Section:
4    "Diagnostic mammogram" means a mammogram obtained using
5diagnostic mammography.
6    "Diagnostic mammography" means a method of screening that
7is designed to evaluate an abnormality in a breast, including
8an abnormality seen or suspected on a screening mammogram or a
9subjective or objective abnormality otherwise detected in the
10breast.
11    "Low-dose mammography" means the x-ray examination of the
12breast using equipment dedicated specifically for mammography,
13including the x-ray tube, filter, compression device, and
14image receptor, with radiation exposure delivery of less than
151 rad per breast for 2 views of an average size breast. The
16term also includes digital mammography and includes breast
17tomosynthesis.
18    "Breast tomosynthesis" means a radiologic procedure that
19involves the acquisition of projection images over the
20stationary breast to produce cross-sectional digital
21three-dimensional images of the breast.
22    If, at any time, the Secretary of the United States
23Department of Health and Human Services, or its successor
24agency, promulgates rules or regulations to be published in
25the Federal Register or publishes a comment in the Federal
26Register or issues an opinion, guidance, or other action that

 

 

10300HB4180ham002- 24 -LRB103 34255 RPS 70899 a

1would require the State, pursuant to any provision of the
2Patient Protection and Affordable Care Act (Public Law
3111-148), including, but not limited to, 42 U.S.C.
418031(d)(3)(B) or any successor provision, to defray the cost
5of any coverage for breast tomosynthesis outlined in this
6subsection, then the requirement that an insurer cover breast
7tomosynthesis is inoperative other than any such coverage
8authorized under Section 1902 of the Social Security Act, 42
9U.S.C. 1396a, and the State shall not assume any obligation
10for the cost of coverage for breast tomosynthesis set forth in
11this subsection.
12    (a-5) Coverage as described in subsection (a) shall be
13provided at no cost to the enrollee and shall not be applied to
14an annual or lifetime maximum benefit.
15    (b) No contract or evidence of coverage issued by a health
16maintenance organization that provides for the surgical
17procedure known as a mastectomy shall be issued, amended,
18delivered, or renewed in this State on or after July 3, 2001
19(the effective date of Public Act 92-0048) this amendatory Act
20of the 92nd General Assembly unless that coverage also
21provides for prosthetic devices or reconstructive surgery
22incident to the mastectomy, providing that the mastectomy is
23performed after July 3, 2001 the effective date of this
24amendatory Act. Coverage for breast reconstruction in
25connection with a mastectomy shall include:
26        (1) reconstruction of the breast upon which the

 

 

10300HB4180ham002- 25 -LRB103 34255 RPS 70899 a

1    mastectomy has been performed;
2        (2) surgery and reconstruction of the other breast to
3    produce a symmetrical appearance; and
4        (3) prostheses and treatment for physical
5    complications at all stages of mastectomy, including
6    lymphedemas.
7Care shall be determined in consultation with the attending
8physician and the patient. The offered coverage for prosthetic
9devices and reconstructive surgery shall be subject to the
10deductible and coinsurance conditions applied to the
11mastectomy and all other terms and conditions applicable to
12other benefits. When a mastectomy is performed and there is no
13evidence of malignancy, then the offered coverage may be
14limited to the provision of prosthetic devices and
15reconstructive surgery to within 2 years after the date of the
16mastectomy. As used in this Section, "mastectomy" means the
17removal of all or part of the breast for medically necessary
18reasons, as determined by a licensed physician.
19    Written notice of the availability of coverage under this
20Section shall be delivered to the enrollee upon enrollment and
21annually thereafter. A health maintenance organization may not
22deny to an enrollee eligibility, or continued eligibility, to
23enroll or to renew coverage under the terms of the plan solely
24for the purpose of avoiding the requirements of this Section.
25A health maintenance organization may not penalize or reduce
26or limit the reimbursement of an attending provider or provide

 

 

10300HB4180ham002- 26 -LRB103 34255 RPS 70899 a

1incentives (monetary or otherwise) to an attending provider to
2induce the provider to provide care to an insured in a manner
3inconsistent with this Section.
4    (c) Rulemaking authority to implement this amendatory Act
5of the 95th General Assembly, if any, is conditioned on the
6rules being adopted in accordance with all provisions of the
7Illinois Administrative Procedure Act and all rules and
8procedures of the Joint Committee on Administrative Rules; any
9purported rule not so adopted, for whatever reason, is
10unauthorized.
11(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
 
12    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
13    Sec. 5-3. Insurance Code provisions.
14    (a) Health Maintenance Organizations shall be subject to
15the provisions of Sections 133, 134, 136, 137, 139, 140,
16141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
17154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
18355.2, 355.3, 355b, 355c, 356f, 356g, 356g.5-1, 356m, 356q,
19356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
20356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
21356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
22356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
23356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
24356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
25356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,

 

 

10300HB4180ham002- 27 -LRB103 34255 RPS 70899 a

1356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
2356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
3356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
4368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
5408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
6subsection (2) of Section 367, and Articles IIA, VIII 1/2,
7XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
8Illinois Insurance Code.
9    (b) For purposes of the Illinois Insurance Code, except
10for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
11Health Maintenance Organizations in the following categories
12are deemed to be "domestic companies":
13        (1) a corporation authorized under the Dental Service
14    Plan Act or the Voluntary Health Services Plans Act;
15        (2) a corporation organized under the laws of this
16    State; or
17        (3) a corporation organized under the laws of another
18    state, 30% or more of the enrollees of which are residents
19    of this State, except a corporation subject to
20    substantially the same requirements in its state of
21    organization as is a "domestic company" under Article VIII
22    1/2 of the Illinois Insurance Code.
23    (c) In considering the merger, consolidation, or other
24acquisition of control of a Health Maintenance Organization
25pursuant to Article VIII 1/2 of the Illinois Insurance Code,
26        (1) the Director shall give primary consideration to

 

 

10300HB4180ham002- 28 -LRB103 34255 RPS 70899 a

1    the continuation of benefits to enrollees and the
2    financial conditions of the acquired Health Maintenance
3    Organization after the merger, consolidation, or other
4    acquisition of control takes effect;
5        (2)(i) the criteria specified in subsection (1)(b) of
6    Section 131.8 of the Illinois Insurance Code shall not
7    apply and (ii) the Director, in making his determination
8    with respect to the merger, consolidation, or other
9    acquisition of control, need not take into account the
10    effect on competition of the merger, consolidation, or
11    other acquisition of control;
12        (3) the Director shall have the power to require the
13    following information:
14            (A) certification by an independent actuary of the
15        adequacy of the reserves of the Health Maintenance
16        Organization sought to be acquired;
17            (B) pro forma financial statements reflecting the
18        combined balance sheets of the acquiring company and
19        the Health Maintenance Organization sought to be
20        acquired as of the end of the preceding year and as of
21        a date 90 days prior to the acquisition, as well as pro
22        forma financial statements reflecting projected
23        combined operation for a period of 2 years;
24            (C) a pro forma business plan detailing an
25        acquiring party's plans with respect to the operation
26        of the Health Maintenance Organization sought to be

 

 

10300HB4180ham002- 29 -LRB103 34255 RPS 70899 a

1        acquired for a period of not less than 3 years; and
2            (D) such other information as the Director shall
3        require.
4    (d) The provisions of Article VIII 1/2 of the Illinois
5Insurance Code and this Section 5-3 shall apply to the sale by
6any health maintenance organization of greater than 10% of its
7enrollee population (including, without limitation, the health
8maintenance organization's right, title, and interest in and
9to its health care certificates).
10    (e) In considering any management contract or service
11agreement subject to Section 141.1 of the Illinois Insurance
12Code, the Director (i) shall, in addition to the criteria
13specified in Section 141.2 of the Illinois Insurance Code,
14take into account the effect of the management contract or
15service agreement on the continuation of benefits to enrollees
16and the financial condition of the health maintenance
17organization to be managed or serviced, and (ii) need not take
18into account the effect of the management contract or service
19agreement on competition.
20    (f) Except for small employer groups as defined in the
21Small Employer Rating, Renewability and Portability Health
22Insurance Act and except for medicare supplement policies as
23defined in Section 363 of the Illinois Insurance Code, a
24Health Maintenance Organization may by contract agree with a
25group or other enrollment unit to effect refunds or charge
26additional premiums under the following terms and conditions:

 

 

10300HB4180ham002- 30 -LRB103 34255 RPS 70899 a

1        (i) the amount of, and other terms and conditions with
2    respect to, the refund or additional premium are set forth
3    in the group or enrollment unit contract agreed in advance
4    of the period for which a refund is to be paid or
5    additional premium is to be charged (which period shall
6    not be less than one year); and
7        (ii) the amount of the refund or additional premium
8    shall not exceed 20% of the Health Maintenance
9    Organization's profitable or unprofitable experience with
10    respect to the group or other enrollment unit for the
11    period (and, for purposes of a refund or additional
12    premium, the profitable or unprofitable experience shall
13    be calculated taking into account a pro rata share of the
14    Health Maintenance Organization's administrative and
15    marketing expenses, but shall not include any refund to be
16    made or additional premium to be paid pursuant to this
17    subsection (f)). The Health Maintenance Organization and
18    the group or enrollment unit may agree that the profitable
19    or unprofitable experience may be calculated taking into
20    account the refund period and the immediately preceding 2
21    plan years.
22    The Health Maintenance Organization shall include a
23statement in the evidence of coverage issued to each enrollee
24describing the possibility of a refund or additional premium,
25and upon request of any group or enrollment unit, provide to
26the group or enrollment unit a description of the method used

 

 

10300HB4180ham002- 31 -LRB103 34255 RPS 70899 a

1to calculate (1) the Health Maintenance Organization's
2profitable experience with respect to the group or enrollment
3unit and the resulting refund to the group or enrollment unit
4or (2) the Health Maintenance Organization's unprofitable
5experience with respect to the group or enrollment unit and
6the resulting additional premium to be paid by the group or
7enrollment unit.
8    In no event shall the Illinois Health Maintenance
9Organization Guaranty Association be liable to pay any
10contractual obligation of an insolvent organization to pay any
11refund authorized under this Section.
12    (g) Rulemaking authority to implement Public Act 95-1045,
13if any, is conditioned on the rules being adopted in
14accordance with all provisions of the Illinois Administrative
15Procedure Act and all rules and procedures of the Joint
16Committee on Administrative Rules; any purported rule not so
17adopted, for whatever reason, is unauthorized.
18(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
19102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
201-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
21eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
22102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
231-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
24eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
25103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
266-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,

 

 

10300HB4180ham002- 32 -LRB103 34255 RPS 70899 a

1eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
2    Section 25. The Illinois Public Aid Code is amended by
3changing Section 5-5 as follows:
 
4    (305 ILCS 5/5-5)
5    Sec. 5-5. Medical services. The Illinois Department, by
6rule, shall determine the quantity and quality of and the rate
7of reimbursement for the medical assistance for which payment
8will be authorized, and the medical services to be provided,
9which may include all or part of the following: (1) inpatient
10hospital services; (2) outpatient hospital services; (3) other
11laboratory and X-ray services; (4) skilled nursing home
12services; (5) physicians' services whether furnished in the
13office, the patient's home, a hospital, a skilled nursing
14home, or elsewhere; (6) medical care, or any other type of
15remedial care furnished by licensed practitioners; (7) home
16health care services; (8) private duty nursing service; (9)
17clinic services; (10) dental services, including prevention
18and treatment of periodontal disease and dental caries disease
19for pregnant individuals, provided by an individual licensed
20to practice dentistry or dental surgery; for purposes of this
21item (10), "dental services" means diagnostic, preventive, or
22corrective procedures provided by or under the supervision of
23a dentist in the practice of his or her profession; (11)
24physical therapy and related services; (12) prescribed drugs,

 

 

10300HB4180ham002- 33 -LRB103 34255 RPS 70899 a

1dentures, and prosthetic devices; and eyeglasses prescribed by
2a physician skilled in the diseases of the eye, or by an
3optometrist, whichever the person may select; (13) other
4diagnostic, screening, preventive, and rehabilitative
5services, including to ensure that the individual's need for
6intervention or treatment of mental disorders or substance use
7disorders or co-occurring mental health and substance use
8disorders is determined using a uniform screening, assessment,
9and evaluation process inclusive of criteria, for children and
10adults; for purposes of this item (13), a uniform screening,
11assessment, and evaluation process refers to a process that
12includes an appropriate evaluation and, as warranted, a
13referral; "uniform" does not mean the use of a singular
14instrument, tool, or process that all must utilize; (14)
15transportation and such other expenses as may be necessary;
16(15) medical treatment of sexual assault survivors, as defined
17in Section 1a of the Sexual Assault Survivors Emergency
18Treatment Act, for injuries sustained as a result of the
19sexual assault, including examinations and laboratory tests to
20discover evidence which may be used in criminal proceedings
21arising from the sexual assault; (16) the diagnosis and
22treatment of sickle cell anemia; (16.5) services performed by
23a chiropractic physician licensed under the Medical Practice
24Act of 1987 and acting within the scope of his or her license,
25including, but not limited to, chiropractic manipulative
26treatment; and (17) any other medical care, and any other type

 

 

10300HB4180ham002- 34 -LRB103 34255 RPS 70899 a

1of remedial care recognized under the laws of this State. The
2term "any other type of remedial care" shall include nursing
3care and nursing home service for persons who rely on
4treatment by spiritual means alone through prayer for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
11Article.
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance
16under this Article.
17    Notwithstanding any other provision of this Section, all
18tobacco cessation medications approved by the United States
19Food and Drug Administration and all individual and group
20tobacco cessation counseling services and telephone-based
21counseling services and tobacco cessation medications provided
22through the Illinois Tobacco Quitline shall be covered under
23the medical assistance program for persons who are otherwise
24eligible for assistance under this Article. The Department
25shall comply with all federal requirements necessary to obtain
26federal financial participation, as specified in 42 CFR

 

 

10300HB4180ham002- 35 -LRB103 34255 RPS 70899 a

1433.15(b)(7), for telephone-based counseling services provided
2through the Illinois Tobacco Quitline, including, but not
3limited to: (i) entering into a memorandum of understanding or
4interagency agreement with the Department of Public Health, as
5administrator of the Illinois Tobacco Quitline; and (ii)
6developing a cost allocation plan for Medicaid-allowable
7Illinois Tobacco Quitline services in accordance with 45 CFR
895.507. The Department shall submit the memorandum of
9understanding or interagency agreement, the cost allocation
10plan, and all other necessary documentation to the Centers for
11Medicare and Medicaid Services for review and approval.
12Coverage under this paragraph shall be contingent upon federal
13approval.
14    Notwithstanding any other provision of this Code, the
15Illinois Department may not require, as a condition of payment
16for any laboratory test authorized under this Article, that a
17physician's handwritten signature appear on the laboratory
18test order form. The Illinois Department may, however, impose
19other appropriate requirements regarding laboratory test order
20documentation.
21    Upon receipt of federal approval of an amendment to the
22Illinois Title XIX State Plan for this purpose, the Department
23shall authorize the Chicago Public Schools (CPS) to procure a
24vendor or vendors to manufacture eyeglasses for individuals
25enrolled in a school within the CPS system. CPS shall ensure
26that its vendor or vendors are enrolled as providers in the

 

 

10300HB4180ham002- 36 -LRB103 34255 RPS 70899 a

1medical assistance program and in any capitated Medicaid
2managed care entity (MCE) serving individuals enrolled in a
3school within the CPS system. Under any contract procured
4under this provision, the vendor or vendors must serve only
5individuals enrolled in a school within the CPS system. Claims
6for services provided by CPS's vendor or vendors to recipients
7of benefits in the medical assistance program under this Code,
8the Children's Health Insurance Program, or the Covering ALL
9KIDS Health Insurance Program shall be submitted to the
10Department or the MCE in which the individual is enrolled for
11payment and shall be reimbursed at the Department's or the
12MCE's established rates or rate methodologies for eyeglasses.
13    On and after July 1, 2012, the Department of Healthcare
14and Family Services may provide the following services to
15persons eligible for assistance under this Article who are
16participating in education, training or employment programs
17operated by the Department of Human Services as successor to
18the Department of Public Aid:
19        (1) dental services provided by or under the
20    supervision of a dentist; and
21        (2) eyeglasses prescribed by a physician skilled in
22    the diseases of the eye, or by an optometrist, whichever
23    the person may select.
24    On and after July 1, 2018, the Department of Healthcare
25and Family Services shall provide dental services to any adult
26who is otherwise eligible for assistance under the medical

 

 

10300HB4180ham002- 37 -LRB103 34255 RPS 70899 a

1assistance program. As used in this paragraph, "dental
2services" means diagnostic, preventative, restorative, or
3corrective procedures, including procedures and services for
4the prevention and treatment of periodontal disease and dental
5caries disease, provided by an individual who is licensed to
6practice dentistry or dental surgery or who is under the
7supervision of a dentist in the practice of his or her
8profession.
9    On and after July 1, 2018, targeted dental services, as
10set forth in Exhibit D of the Consent Decree entered by the
11United States District Court for the Northern District of
12Illinois, Eastern Division, in the matter of Memisovski v.
13Maram, Case No. 92 C 1982, that are provided to adults under
14the medical assistance program shall be established at no less
15than the rates set forth in the "New Rate" column in Exhibit D
16of the Consent Decree for targeted dental services that are
17provided to persons under the age of 18 under the medical
18assistance program.
19    Notwithstanding any other provision of this Code and
20subject to federal approval, the Department may adopt rules to
21allow a dentist who is volunteering his or her service at no
22cost to render dental services through an enrolled
23not-for-profit health clinic without the dentist personally
24enrolling as a participating provider in the medical
25assistance program. A not-for-profit health clinic shall
26include a public health clinic or Federally Qualified Health

 

 

10300HB4180ham002- 38 -LRB103 34255 RPS 70899 a

1Center or other enrolled provider, as determined by the
2Department, through which dental services covered under this
3Section are performed. The Department shall establish a
4process for payment of claims for reimbursement for covered
5dental services rendered under this provision.
6    On and after January 1, 2022, the Department of Healthcare
7and Family Services shall administer and regulate a
8school-based dental program that allows for the out-of-office
9delivery of preventative dental services in a school setting
10to children under 19 years of age. The Department shall
11establish, by rule, guidelines for participation by providers
12and set requirements for follow-up referral care based on the
13requirements established in the Dental Office Reference Manual
14published by the Department that establishes the requirements
15for dentists participating in the All Kids Dental School
16Program. Every effort shall be made by the Department when
17developing the program requirements to consider the different
18geographic differences of both urban and rural areas of the
19State for initial treatment and necessary follow-up care. No
20provider shall be charged a fee by any unit of local government
21to participate in the school-based dental program administered
22by the Department. Nothing in this paragraph shall be
23construed to limit or preempt a home rule unit's or school
24district's authority to establish, change, or administer a
25school-based dental program in addition to, or independent of,
26the school-based dental program administered by the

 

 

10300HB4180ham002- 39 -LRB103 34255 RPS 70899 a

1Department.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in
4accordance with the classes of persons designated in Section
55-2.
6    The Department of Healthcare and Family Services must
7provide coverage and reimbursement for amino acid-based
8elemental formulas, regardless of delivery method, for the
9diagnosis and treatment of (i) eosinophilic disorders and (ii)
10short bowel syndrome when the prescribing physician has issued
11a written order stating that the amino acid-based elemental
12formula is medically necessary.
13    The Illinois Department shall authorize the provision of,
14and shall authorize payment for, screening by low-dose
15mammography for the presence of occult breast cancer for
16individuals 35 years of age or older who are eligible for
17medical assistance under this Article, as follows:
18        (A) A baseline mammogram for individuals 35 to 39
19    years of age.
20        (B) An annual mammogram for individuals 40 years of
21    age or older.
22        (C) A mammogram at the age and intervals considered
23    medically necessary by the individual's health care
24    provider for individuals under 40 years of age and having
25    a family history of breast cancer, prior personal history
26    of breast cancer, positive genetic testing, or other risk

 

 

10300HB4180ham002- 40 -LRB103 34255 RPS 70899 a

1    factors.
2        (D) A comprehensive ultrasound screening and MRI of an
3    entire breast or breasts if a mammogram demonstrates
4    heterogeneous or dense breast tissue or when medically
5    necessary as determined by a physician licensed to
6    practice medicine in all of its branches.
7        (E) A screening MRI when medically necessary, as
8    determined by a physician licensed to practice medicine in
9    all of its branches.
10        (F) A diagnostic mammogram when medically necessary,
11    as determined by a physician licensed to practice medicine
12    in all its branches, advanced practice registered nurse,
13    or physician assistant.
14        (G) Molecular breast imaging (MBI) and MRI of an
15    entire 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, advanced
19    practice registered nurse, or physician assistant.
20    The Department shall not impose a deductible, coinsurance,
21copayment, or any other cost-sharing requirement on the
22coverage provided under this paragraph; except that this
23sentence does not apply to coverage of diagnostic mammograms
24to the extent such coverage would disqualify a high-deductible
25health plan from eligibility for a health savings account
26pursuant to Section 223 of the Internal Revenue Code (26

 

 

10300HB4180ham002- 41 -LRB103 34255 RPS 70899 a

1U.S.C. 223).
2    All screenings shall include a physical breast exam,
3instruction on self-examination and information regarding the
4frequency of self-examination and its value as a preventative
5tool.
6     For purposes of this Section:
7    "Diagnostic mammogram" means a mammogram obtained using
8diagnostic mammography.
9    "Diagnostic mammography" means a method of screening that
10is designed to evaluate an abnormality in a breast, including
11an abnormality seen or suspected on a screening mammogram or a
12subjective or objective abnormality otherwise detected in the
13breast.
14    "Low-dose mammography" means the x-ray examination of the
15breast using equipment dedicated specifically for mammography,
16including the x-ray tube, filter, compression device, and
17image receptor, with an average radiation exposure delivery of
18less than one rad per breast for 2 views of an average size
19breast. The term also includes digital mammography and
20includes breast tomosynthesis.
21    "Breast tomosynthesis" means a radiologic procedure that
22involves the acquisition of projection images over the
23stationary breast to produce cross-sectional digital
24three-dimensional images of the breast.
25    If, at any time, the Secretary of the United States
26Department of Health and Human Services, or its successor

 

 

10300HB4180ham002- 42 -LRB103 34255 RPS 70899 a

1agency, promulgates rules or regulations to be published in
2the Federal Register or publishes a comment in the Federal
3Register or issues an opinion, guidance, or other action that
4would require the State, pursuant to any provision of the
5Patient Protection and Affordable Care Act (Public Law
6111-148), including, but not limited to, 42 U.S.C.
718031(d)(3)(B) or any successor provision, to defray the cost
8of any coverage for breast tomosynthesis outlined in this
9paragraph, then the requirement that an insurer cover breast
10tomosynthesis is inoperative other than any such coverage
11authorized under Section 1902 of the Social Security Act, 42
12U.S.C. 1396a, and the State shall not assume any obligation
13for the cost of coverage for breast tomosynthesis set forth in
14this paragraph.
15    On and after January 1, 2016, the Department shall ensure
16that all networks of care for adult clients of the Department
17include access to at least one breast imaging Center of
18Imaging Excellence as certified by the American College of
19Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall
22be reimbursed for screening and diagnostic mammography at the
23same rate as the Medicare program's rates, including the
24increased reimbursement for digital mammography and, after
25January 1, 2023 (the effective date of Public Act 102-1018),
26breast tomosynthesis.

 

 

10300HB4180ham002- 43 -LRB103 34255 RPS 70899 a

1    The Department shall convene an expert panel including
2representatives of hospitals, free-standing mammography
3facilities, and doctors, including radiologists, to establish
4quality standards for mammography.
5    On and after January 1, 2017, providers participating in a
6breast cancer treatment quality improvement program approved
7by the Department shall be reimbursed for breast cancer
8treatment at a rate that is no lower than 95% of the Medicare
9program's rates for the data elements included in the breast
10cancer treatment quality program.
11    The Department shall convene an expert panel, including
12representatives of hospitals, free-standing breast cancer
13treatment centers, breast cancer quality organizations, and
14doctors, including radiologists that are trained in all forms
15of FDA approved breast imaging technologies, breast surgeons,
16reconstructive breast surgeons, oncologists, and primary care
17providers to establish quality standards for breast cancer
18treatment.
19    Subject to federal approval, the Department shall
20establish a rate methodology for mammography at federally
21qualified health centers and other encounter-rate clinics.
22These clinics or centers may also collaborate with other
23hospital-based mammography facilities. By January 1, 2016, the
24Department shall report to the General Assembly on the status
25of the provision set forth in this paragraph.
26    The Department shall establish a methodology to remind

 

 

10300HB4180ham002- 44 -LRB103 34255 RPS 70899 a

1individuals who are age-appropriate for screening mammography,
2but who have not received a mammogram within the previous 18
3months, of the importance and benefit of screening
4mammography. The Department shall work with experts in breast
5cancer outreach and patient navigation to optimize these
6reminders and shall establish a methodology for evaluating
7their effectiveness and modifying the methodology based on the
8evaluation.
9    The Department shall establish a performance goal for
10primary care providers with respect to their female patients
11over age 40 receiving an annual mammogram. This performance
12goal shall be used to provide additional reimbursement in the
13form of a quality performance bonus to primary care providers
14who meet that goal.
15    The Department shall devise a means of case-managing or
16patient navigation for beneficiaries diagnosed with breast
17cancer. This program shall initially operate as a pilot
18program in areas of the State with the highest incidence of
19mortality related to breast cancer. At least one pilot program
20site shall be in the metropolitan Chicago area and at least one
21site shall be outside the metropolitan Chicago area. On or
22after July 1, 2016, the pilot program shall be expanded to
23include one site in western Illinois, one site in southern
24Illinois, one site in central Illinois, and 4 sites within
25metropolitan Chicago. An evaluation of the pilot program shall
26be carried out measuring health outcomes and cost of care for

 

 

10300HB4180ham002- 45 -LRB103 34255 RPS 70899 a

1those served by the pilot program compared to similarly
2situated patients who are not served by the pilot program.
3    The Department shall require all networks of care to
4develop a means either internally or by contract with experts
5in navigation and community outreach to navigate cancer
6patients to comprehensive care in a timely fashion. The
7Department shall require all networks of care to include
8access for patients diagnosed with cancer to at least one
9academic commission on cancer-accredited cancer program as an
10in-network covered benefit.
11    The Department shall provide coverage and reimbursement
12for a human papillomavirus (HPV) vaccine that is approved for
13marketing by the federal Food and Drug Administration for all
14persons between the ages of 9 and 45. Subject to federal
15approval, the Department shall provide coverage and
16reimbursement for a human papillomavirus (HPV) vaccine for
17persons of the age of 46 and above who have been diagnosed with
18cervical dysplasia with a high risk of recurrence or
19progression. The Department shall disallow any
20preauthorization requirements for the administration of the
21human papillomavirus (HPV) vaccine.
22    On or after July 1, 2022, individuals who are otherwise
23eligible for medical assistance under this Article shall
24receive coverage for perinatal depression screenings for the
2512-month period beginning on the last day of their pregnancy.
26Medical assistance coverage under this paragraph shall be

 

 

10300HB4180ham002- 46 -LRB103 34255 RPS 70899 a

1conditioned on the use of a screening instrument approved by
2the Department.
3    Any medical or health care provider shall immediately
4recommend, to any pregnant individual who is being provided
5prenatal services and is suspected of having a substance use
6disorder as defined in the Substance Use Disorder Act,
7referral to a local substance use disorder treatment program
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department
14of Human Services.
15    All medical providers providing medical assistance to
16pregnant individuals under this Code shall receive information
17from the Department on the availability of services under any
18program providing case management services for addicted
19individuals, including information on appropriate referrals
20for other social services that may be needed by addicted
21individuals in addition to treatment for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through
25a public awareness campaign, may provide information
26concerning treatment for alcoholism and drug abuse and

 

 

10300HB4180ham002- 47 -LRB103 34255 RPS 70899 a

1addiction, prenatal health care, and other pertinent programs
2directed at reducing the number of drug-affected infants born
3to recipients of medical assistance.
4    Neither the Department of Healthcare and Family Services
5nor the Department of Human Services shall sanction the
6recipient solely on the basis of the recipient's substance
7abuse.
8    The Illinois Department shall establish such regulations
9governing the dispensing of health services under this Article
10as it shall deem appropriate. The Department should seek the
11advice of formal professional advisory committees appointed by
12the Director of the Illinois Department for the purpose of
13providing regular advice on policy and administrative matters,
14information dissemination and educational activities for
15medical and health care providers, and consistency in
16procedures to the Illinois Department.
17    The Illinois Department may develop and contract with
18Partnerships of medical providers to arrange medical services
19for persons eligible under Section 5-2 of this Code.
20Implementation of this Section may be by demonstration
21projects in certain geographic areas. The Partnership shall be
22represented by a sponsor organization. The Department, by
23rule, shall develop qualifications for sponsors of
24Partnerships. Nothing in this Section shall be construed to
25require that the sponsor organization be a medical
26organization.

 

 

10300HB4180ham002- 48 -LRB103 34255 RPS 70899 a

1    The sponsor must negotiate formal written contracts with
2medical providers for physician services, inpatient and
3outpatient hospital care, home health services, treatment for
4alcoholism and substance abuse, and other services determined
5necessary by the Illinois Department by rule for delivery by
6Partnerships. Physician services must include prenatal and
7obstetrical care. The Illinois Department shall reimburse
8medical services delivered by Partnership providers to clients
9in target areas according to provisions of this Article and
10the Illinois Health Finance Reform Act, except that:
11        (1) Physicians participating in a Partnership and
12    providing certain services, which shall be determined by
13    the Illinois Department, to persons in areas covered by
14    the Partnership may receive an additional surcharge for
15    such services.
16        (2) The Department may elect to consider and negotiate
17    financial incentives to encourage the development of
18    Partnerships and the efficient delivery of medical care.
19        (3) Persons receiving medical services through
20    Partnerships may receive medical and case management
21    services above the level usually offered through the
22    medical assistance program.
23    Medical providers shall be required to meet certain
24qualifications to participate in Partnerships to ensure the
25delivery of high quality medical services. These
26qualifications shall be determined by rule of the Illinois

 

 

10300HB4180ham002- 49 -LRB103 34255 RPS 70899 a

1Department and may be higher than qualifications for
2participation in the medical assistance program. Partnership
3sponsors may prescribe reasonable additional qualifications
4for participation by medical providers, only with the prior
5written approval of the Illinois Department.
6    Nothing in this Section shall limit the free choice of
7practitioners, hospitals, and other providers of medical
8services by clients. In order to ensure patient freedom of
9choice, the Illinois Department shall immediately promulgate
10all rules and take all other necessary actions so that
11provided services may be accessed from therapeutically
12certified optometrists to the full extent of the Illinois
13Optometric Practice Act of 1987 without discriminating between
14service providers.
15    The Department shall apply for a waiver from the United
16States Health Care Financing Administration to allow for the
17implementation of Partnerships under this Section.
18    The Illinois Department shall require health care
19providers to maintain records that document the medical care
20and services provided to recipients of Medical Assistance
21under this Article. Such records must be retained for a period
22of not less than 6 years from the date of service or as
23provided by applicable State law, whichever period is longer,
24except that if an audit is initiated within the required
25retention period then the records must be retained until the
26audit is completed and every exception is resolved. The

 

 

10300HB4180ham002- 50 -LRB103 34255 RPS 70899 a

1Illinois Department shall require health care providers to
2make available, when authorized by the patient, in writing,
3the medical records in a timely fashion to other health care
4providers who are treating or serving persons eligible for
5Medical Assistance under this Article. All dispensers of
6medical services shall be required to maintain and retain
7business and professional records sufficient to fully and
8accurately document the nature, scope, details and receipt of
9the health care provided to persons eligible for medical
10assistance under this Code, in accordance with regulations
11promulgated by the Illinois Department. The rules and
12regulations shall require that proof of the receipt of
13prescription drugs, dentures, prosthetic devices and
14eyeglasses by eligible persons under this Section accompany
15each claim for reimbursement submitted by the dispenser of
16such medical services. No such claims for reimbursement shall
17be approved for payment by the Illinois Department without
18such proof of receipt, unless the Illinois Department shall
19have put into effect and shall be operating a system of
20post-payment audit and review which shall, on a sampling
21basis, be deemed adequate by the Illinois Department to assure
22that such drugs, dentures, prosthetic devices and eyeglasses
23for which payment is being made are actually being received by
24eligible recipients. Within 90 days after September 16, 1984
25(the effective date of Public Act 83-1439), the Illinois
26Department shall establish a current list of acquisition costs

 

 

10300HB4180ham002- 51 -LRB103 34255 RPS 70899 a

1for all prosthetic devices and any other items recognized as
2medical equipment and supplies reimbursable under this Article
3and shall update such list on a quarterly basis, except that
4the acquisition costs of all prescription drugs shall be
5updated no less frequently than every 30 days as required by
6Section 5-5.12.
7    Notwithstanding any other law to the contrary, the
8Illinois Department shall, within 365 days after July 22, 2013
9(the effective date of Public Act 98-104), establish
10procedures to permit skilled care facilities licensed under
11the Nursing Home Care Act to submit monthly billing claims for
12reimbursement purposes. Following development of these
13procedures, the Department shall, by July 1, 2016, test the
14viability of the new system and implement any necessary
15operational or structural changes to its information
16technology platforms in order to allow for the direct
17acceptance and payment of nursing home claims.
18    Notwithstanding any other law to the contrary, the
19Illinois Department shall, within 365 days after August 15,
202014 (the effective date of Public Act 98-963), establish
21procedures to permit ID/DD facilities licensed under the ID/DD
22Community Care Act and MC/DD facilities licensed under the
23MC/DD Act to submit monthly billing claims for reimbursement
24purposes. Following development of these procedures, the
25Department shall have an additional 365 days to test the
26viability of the new system and to ensure that any necessary

 

 

10300HB4180ham002- 52 -LRB103 34255 RPS 70899 a

1operational or structural changes to its information
2technology platforms are implemented.
3    The Illinois Department shall require all dispensers of
4medical services, other than an individual practitioner or
5group of practitioners, desiring to participate in the Medical
6Assistance program established under this Article to disclose
7all financial, beneficial, ownership, equity, surety or other
8interests in any and all firms, corporations, partnerships,
9associations, business enterprises, joint ventures, agencies,
10institutions or other legal entities providing any form of
11health care services in this State under this Article.
12    The Illinois Department may require that all dispensers of
13medical services desiring to participate in the medical
14assistance program established under this Article disclose,
15under such terms and conditions as the Illinois Department may
16by rule establish, all inquiries from clients and attorneys
17regarding medical bills paid by the Illinois Department, which
18inquiries could indicate potential existence of claims or
19liens for the Illinois Department.
20    Enrollment of a vendor shall be subject to a provisional
21period and shall be conditional for one year. During the
22period of conditional enrollment, the Department may terminate
23the vendor's eligibility to participate in, or may disenroll
24the vendor from, the medical assistance program without cause.
25Unless otherwise specified, such termination of eligibility or
26disenrollment is not subject to the Department's hearing

 

 

10300HB4180ham002- 53 -LRB103 34255 RPS 70899 a

1process. However, a disenrolled vendor may reapply without
2penalty.
3    The Department has the discretion to limit the conditional
4enrollment period for vendors based upon the category of risk
5of the vendor.
6    Prior to enrollment and during the conditional enrollment
7period in the medical assistance program, all vendors shall be
8subject to enhanced oversight, screening, and review based on
9the risk of fraud, waste, and abuse that is posed by the
10category of risk of the vendor. The Illinois Department shall
11establish the procedures for oversight, screening, and review,
12which may include, but need not be limited to: criminal and
13financial background checks; fingerprinting; license,
14certification, and authorization verifications; unscheduled or
15unannounced site visits; database checks; prepayment audit
16reviews; audits; payment caps; payment suspensions; and other
17screening as required by federal or State law.
18    The Department shall define or specify the following: (i)
19by provider notice, the "category of risk of the vendor" for
20each type of vendor, which shall take into account the level of
21screening applicable to a particular category of vendor under
22federal law and regulations; (ii) by rule or provider notice,
23the maximum length of the conditional enrollment period for
24each category of risk of the vendor; and (iii) by rule, the
25hearing rights, if any, afforded to a vendor in each category
26of risk of the vendor that is terminated or disenrolled during

 

 

10300HB4180ham002- 54 -LRB103 34255 RPS 70899 a

1the conditional enrollment period.
2    To be eligible for payment consideration, a vendor's
3payment claim or bill, either as an initial claim or as a
4resubmitted claim following prior rejection, must be received
5by the Illinois Department, or its fiscal intermediary, no
6later than 180 days after the latest date on the claim on which
7medical goods or services were provided, with the following
8exceptions:
9        (1) In the case of a provider whose enrollment is in
10    process by the Illinois Department, the 180-day period
11    shall not begin until the date on the written notice from
12    the Illinois Department that the provider enrollment is
13    complete.
14        (2) In the case of errors attributable to the Illinois
15    Department or any of its claims processing intermediaries
16    which result in an inability to receive, process, or
17    adjudicate a claim, the 180-day period shall not begin
18    until the provider has been notified of the error.
19        (3) In the case of a provider for whom the Illinois
20    Department initiates the monthly billing process.
21        (4) In the case of a provider operated by a unit of
22    local government with a population exceeding 3,000,000
23    when local government funds finance federal participation
24    for claims payments.
25    For claims for services rendered during a period for which
26a recipient received retroactive eligibility, claims must be

 

 

10300HB4180ham002- 55 -LRB103 34255 RPS 70899 a

1filed within 180 days after the Department determines the
2applicant is eligible. For claims for which the Illinois
3Department is not the primary payer, claims must be submitted
4to the Illinois Department within 180 days after the final
5adjudication by the primary payer.
6    In the case of long term care facilities, within 120
7calendar days of receipt by the facility of required
8prescreening information, new admissions with associated
9admission documents shall be submitted through the Medical
10Electronic Data Interchange (MEDI) or the Recipient
11Eligibility Verification (REV) System or shall be submitted
12directly to the Department of Human Services using required
13admission forms. Effective September 1, 2014, admission
14documents, including all prescreening information, must be
15submitted through MEDI or REV. Confirmation numbers assigned
16to an accepted transaction shall be retained by a facility to
17verify timely submittal. Once an admission transaction has
18been completed, all resubmitted claims following prior
19rejection are subject to receipt no later than 180 days after
20the admission transaction has been completed.
21    Claims that are not submitted and received in compliance
22with the foregoing requirements shall not be eligible for
23payment under the medical assistance program, and the State
24shall have no liability for payment of those claims.
25    To the extent consistent with applicable information and
26privacy, security, and disclosure laws, State and federal

 

 

10300HB4180ham002- 56 -LRB103 34255 RPS 70899 a

1agencies and departments shall provide the Illinois Department
2access to confidential and other information and data
3necessary to perform eligibility and payment verifications and
4other Illinois Department functions. This includes, but is not
5limited to: information pertaining to licensure;
6certification; earnings; immigration status; citizenship; wage
7reporting; unearned and earned income; pension income;
8employment; supplemental security income; social security
9numbers; National Provider Identifier (NPI) numbers; the
10National Practitioner Data Bank (NPDB); program and agency
11exclusions; taxpayer identification numbers; tax delinquency;
12corporate information; and death records.
13    The Illinois Department shall enter into agreements with
14State agencies and departments, and is authorized to enter
15into agreements with federal agencies and departments, under
16which such agencies and departments shall share data necessary
17for medical assistance program integrity functions and
18oversight. The Illinois Department shall develop, in
19cooperation with other State departments and agencies, and in
20compliance with applicable federal laws and regulations,
21appropriate and effective methods to share such data. At a
22minimum, and to the extent necessary to provide data sharing,
23the Illinois Department shall enter into agreements with State
24agencies and departments, and is authorized to enter into
25agreements with federal agencies and departments, including,
26but not limited to: the Secretary of State; the Department of

 

 

10300HB4180ham002- 57 -LRB103 34255 RPS 70899 a

1Revenue; the Department of Public Health; the Department of
2Human Services; and the Department of Financial and
3Professional Regulation.
4    Beginning in fiscal year 2013, the Illinois Department
5shall set forth a request for information to identify the
6benefits of a pre-payment, post-adjudication, and post-edit
7claims system with the goals of streamlining claims processing
8and provider reimbursement, reducing the number of pending or
9rejected claims, and helping to ensure a more transparent
10adjudication process through the utilization of: (i) provider
11data verification and provider screening technology; and (ii)
12clinical code editing; and (iii) pre-pay, pre-adjudicated, or
13post-adjudicated predictive modeling with an integrated case
14management system with link analysis. Such a request for
15information shall not be considered as a request for proposal
16or as an obligation on the part of the Illinois Department to
17take any action or acquire any products or services.
18    The Illinois Department shall establish policies,
19procedures, standards and criteria by rule for the
20acquisition, repair and replacement of orthotic and prosthetic
21devices and durable medical equipment. Such rules shall
22provide, but not be limited to, the following services: (1)
23immediate repair or replacement of such devices by recipients;
24and (2) rental, lease, purchase or lease-purchase of durable
25medical equipment in a cost-effective manner, taking into
26consideration the recipient's medical prognosis, the extent of

 

 

10300HB4180ham002- 58 -LRB103 34255 RPS 70899 a

1the recipient's needs, and the requirements and costs for
2maintaining such equipment. Subject to prior approval, such
3rules shall enable a recipient to temporarily acquire and use
4alternative or substitute devices or equipment pending repairs
5or replacements of any device or equipment previously
6authorized for such recipient by the Department.
7Notwithstanding any provision of Section 5-5f to the contrary,
8the Department may, by rule, exempt certain replacement
9wheelchair parts from prior approval and, for wheelchairs,
10wheelchair parts, wheelchair accessories, and related seating
11and positioning items, determine the wholesale price by
12methods other than actual acquisition costs.
13    The Department shall require, by rule, all providers of
14durable medical equipment to be accredited by an accreditation
15organization approved by the federal Centers for Medicare and
16Medicaid Services and recognized by the Department in order to
17bill the Department for providing durable medical equipment to
18recipients. No later than 15 months after the effective date
19of the rule adopted pursuant to this paragraph, all providers
20must meet the accreditation requirement.
21    In order to promote environmental responsibility, meet the
22needs of recipients and enrollees, and achieve significant
23cost savings, the Department, or a managed care organization
24under contract with the Department, may provide recipients or
25managed care enrollees who have a prescription or Certificate
26of Medical Necessity access to refurbished durable medical

 

 

10300HB4180ham002- 59 -LRB103 34255 RPS 70899 a

1equipment under this Section (excluding prosthetic and
2orthotic devices as defined in the Orthotics, Prosthetics, and
3Pedorthics Practice Act and complex rehabilitation technology
4products and associated services) through the State's
5assistive technology program's reutilization program, using
6staff with the Assistive Technology Professional (ATP)
7Certification if the refurbished durable medical equipment:
8(i) is available; (ii) is less expensive, including shipping
9costs, than new durable medical equipment of the same type;
10(iii) is able to withstand at least 3 years of use; (iv) is
11cleaned, disinfected, sterilized, and safe in accordance with
12federal Food and Drug Administration regulations and guidance
13governing the reprocessing of medical devices in health care
14settings; and (v) equally meets the needs of the recipient or
15enrollee. The reutilization program shall confirm that the
16recipient or enrollee is not already in receipt of the same or
17similar equipment from another service provider, and that the
18refurbished durable medical equipment equally meets the needs
19of the recipient or enrollee. Nothing in this paragraph shall
20be construed to limit recipient or enrollee choice to obtain
21new durable medical equipment or place any additional prior
22authorization conditions on enrollees of managed care
23organizations.
24    The Department shall execute, relative to the nursing home
25prescreening project, written inter-agency agreements with the
26Department of Human Services and the Department on Aging, to

 

 

10300HB4180ham002- 60 -LRB103 34255 RPS 70899 a

1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the
5State where they are not currently available or are
6undeveloped; and (iii) notwithstanding any other provision of
7law, subject to federal approval, on and after July 1, 2012, an
8increase in the determination of need (DON) scores from 29 to
937 for applicants for institutional and home and
10community-based long term care; if and only if federal
11approval is not granted, the Department may, in conjunction
12with other affected agencies, implement utilization controls
13or changes in benefit packages to effectuate a similar savings
14amount for this population; and (iv) no later than July 1,
152013, minimum level of care eligibility criteria for
16institutional and home and community-based long term care; and
17(v) no later than October 1, 2013, establish procedures to
18permit long term care providers access to eligibility scores
19for individuals with an admission date who are seeking or
20receiving services from the long term care provider. In order
21to select the minimum level of care eligibility criteria, the
22Governor shall establish a workgroup that includes affected
23agency representatives and stakeholders representing the
24institutional and home and community-based long term care
25interests. This Section shall not restrict the Department from
26implementing lower level of care eligibility criteria for

 

 

10300HB4180ham002- 61 -LRB103 34255 RPS 70899 a

1community-based services in circumstances where federal
2approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation
7and programs for monitoring of utilization of health care
8services and facilities, as it affects persons eligible for
9medical assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The requirement for reporting to the General
25Assembly shall be satisfied by filing copies of the report as
26required by Section 3.1 of the General Assembly Organization

 

 

10300HB4180ham002- 62 -LRB103 34255 RPS 70899 a

1Act, and filing such additional copies with the State
2Government Report Distribution Center for the General Assembly
3as is required under paragraph (t) of Section 7 of the State
4Library Act.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11    On and after July 1, 2012, the Department shall reduce any
12rate of reimbursement for services or other payments or alter
13any methodologies authorized by this Code to reduce any rate
14of reimbursement for services or other payments in accordance
15with Section 5-5e.
16    Because kidney transplantation can be an appropriate,
17cost-effective alternative to renal dialysis when medically
18necessary and notwithstanding the provisions of Section 1-11
19of this Code, beginning October 1, 2014, the Department shall
20cover kidney transplantation for noncitizens with end-stage
21renal disease who are not eligible for comprehensive medical
22benefits, who meet the residency requirements of Section 5-3
23of this Code, and who would otherwise meet the financial
24requirements of the appropriate class of eligible persons
25under Section 5-2 of this Code. To qualify for coverage of
26kidney transplantation, such person must be receiving

 

 

10300HB4180ham002- 63 -LRB103 34255 RPS 70899 a

1emergency renal dialysis services covered by the Department.
2Providers under this Section shall be prior approved and
3certified by the Department to perform kidney transplantation
4and the services under this Section shall be limited to
5services associated with kidney transplantation.
6    Notwithstanding any other provision of this Code to the
7contrary, on or after July 1, 2015, all FDA approved forms of
8medication assisted treatment prescribed for the treatment of
9alcohol dependence or treatment of opioid dependence shall be
10covered under both fee-for-service fee for service and managed
11care medical assistance programs for persons who are otherwise
12eligible for medical assistance under this Article and shall
13not be subject to any (1) utilization control, other than
14those established under the American Society of Addiction
15Medicine patient placement criteria, (2) prior authorization
16mandate, or (3) lifetime restriction limit mandate.
17    On or after July 1, 2015, opioid antagonists prescribed
18for the treatment of an opioid overdose, including the
19medication product, administration devices, and any pharmacy
20fees or hospital fees related to the dispensing, distribution,
21and administration of the opioid antagonist, shall be covered
22under the medical assistance program for persons who are
23otherwise eligible for medical assistance under this Article.
24As used in this Section, "opioid antagonist" means a drug that
25binds to opioid receptors and blocks or inhibits the effect of
26opioids acting on those receptors, including, but not limited

 

 

10300HB4180ham002- 64 -LRB103 34255 RPS 70899 a

1to, naloxone hydrochloride or any other similarly acting drug
2approved by the U.S. Food and Drug Administration. The
3Department shall not impose a copayment on the coverage
4provided for naloxone hydrochloride under the medical
5assistance program.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a
23dental hygienist, as defined under the Illinois Dental
24Practice Act, working under the general supervision of a
25dentist and employed by a federally qualified health center.
26    Within 90 days after October 8, 2021 (the effective date

 

 

10300HB4180ham002- 65 -LRB103 34255 RPS 70899 a

1of Public Act 102-665), the Department shall seek federal
2approval of a State Plan amendment to expand coverage for
3family planning services that includes presumptive eligibility
4to individuals whose income is at or below 208% of the federal
5poverty level. Coverage under this Section shall be effective
6beginning no later than December 1, 2022.
7    Subject to approval by the federal Centers for Medicare
8and Medicaid Services of a Title XIX State Plan amendment
9electing the Program of All-Inclusive Care for the Elderly
10(PACE) as a State Medicaid option, as provided for by Subtitle
11I (commencing with Section 4801) of Title IV of the Balanced
12Budget Act of 1997 (Public Law 105-33) and Part 460
13(commencing with Section 460.2) of Subchapter E of Title 42 of
14the Code of Federal Regulations, PACE program services shall
15become a covered benefit of the medical assistance program,
16subject to criteria established in accordance with all
17applicable laws.
18    Notwithstanding any other provision of this Code,
19community-based pediatric palliative care from a trained
20interdisciplinary team shall be covered under the medical
21assistance program as provided in Section 15 of the Pediatric
22Palliative Care Act.
23    Notwithstanding any other provision of this Code, within
2412 months after June 2, 2022 (the effective date of Public Act
25102-1037) and subject to federal approval, acupuncture
26services performed by an acupuncturist licensed under the

 

 

10300HB4180ham002- 66 -LRB103 34255 RPS 70899 a

1Acupuncture Practice Act who is acting within the scope of his
2or her license shall be covered under the medical assistance
3program. The Department shall apply for any federal waiver or
4State Plan amendment, if required, to implement this
5paragraph. The Department may adopt any rules, including
6standards and criteria, necessary to implement this paragraph.
7    Notwithstanding any other provision of this Code, the
8medical assistance program shall, subject to appropriation and
9federal approval, reimburse hospitals for costs associated
10with a newborn screening test for the presence of
11metachromatic leukodystrophy, as required under the Newborn
12Metabolic Screening Act, at a rate not less than the fee
13charged by the Department of Public Health. The Department
14shall seek federal approval before the implementation of the
15newborn screening test fees by the Department of Public
16Health.
17    Notwithstanding any other provision of this Code,
18beginning on January 1, 2024, subject to federal approval,
19cognitive assessment and care planning services provided to a
20person who experiences signs or symptoms of cognitive
21impairment, as defined by the Diagnostic and Statistical
22Manual of Mental Disorders, Fifth Edition, shall be covered
23under the medical assistance program for persons who are
24otherwise eligible for medical assistance under this Article.
25    Notwithstanding any other provision of this Code,
26medically necessary reconstructive services that are intended

 

 

10300HB4180ham002- 67 -LRB103 34255 RPS 70899 a

1to restore physical appearance shall be covered under the
2medical assistance program for persons who are otherwise
3eligible for medical assistance under this Article. As used in
4this paragraph, "reconstructive services" means treatments
5performed on structures of the body damaged by trauma to
6restore physical appearance.
7(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
8102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
955, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
10eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
11102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
125-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
13102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
141-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
15103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
161-1-24; revised 12-15-23.)
 
17    Section 99. Effective date. This Act takes effect January
181, 2026.".