Illinois General Assembly - Full Text of HB4394
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Full Text of HB4394  101st General Assembly




State of Illinois
2019 and 2020


Introduced 1/29/2020, by Rep. Patrick Windhorst


5 ILCS 375/6  from Ch. 127, par. 526
5 ILCS 375/6.1  from Ch. 127, par. 526.1
305 ILCS 5/5-5  from Ch. 23, par. 5-5
305 ILCS 5/5-8  from Ch. 23, par. 5-8
305 ILCS 5/5-9  from Ch. 23, par. 5-9
305 ILCS 5/6-1  from Ch. 23, par. 6-1
410 ILCS 230/4-100  from Ch. 111 1/2, par. 4604-100

    Amends the State Employees Group Insurance Act of 1971, the Illinois Public Aid Code, and the Problem Pregnancy Health Services and Care Act. Restores the provisions that were amended by Public Act 100-538 to the form in which they existed before their amendment by Public Act 100-538.

LRB101 16543 KTG 65927 b






HB4394LRB101 16543 KTG 65927 b

1    AN ACT concerning abortion.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit the
18non-contributory portion of any such program to include the
19expenses of obtaining an abortion, induced miscarriage or
20induced premature birth unless, in the opinion of a physician,
21such procedures are necessary for the preservation of the life
22of the woman seeking such treatment, or except an induced
23premature birth intended to produce a live viable child and



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1such procedure is necessary for the health of the mother or the
2unborn child. The program may also include coverage for those
3who rely on treatment by prayer or spiritual means alone for
4healing in accordance with the tenets and practice of a
5recognized religious denomination.
6    The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits and
11as optional benefits, the medical services of practitioners in
12all categories licensed under the Medical Practice Act of 1987,
13(3) to include reasonable controls, which may include
14deductible and co-insurance provisions, applicable to some or
15all of the benefits, or a coordination of benefits provision,
16to prevent or minimize unnecessary utilization of the various
17hospital, surgical and medical expenses to be provided and to
18provide reasonable assurance of stability of the program, and
19(4) to provide benefits to the extent possible to members
20throughout the State, wherever located, on an equitable basis.
21Notwithstanding any other provision of this Section or Act, for
22all members or dependents who are eligible for benefits under
23Social Security or the Railroad Retirement system or who had
24sufficient Medicare-covered government employment, the
25Department shall reduce benefits which would otherwise be paid
26by Medicare, by the amount of benefits for which the member or



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1dependents are eligible under Medicare, except that such
2reduction in benefits shall apply only to those members or
3dependents who (1) first become eligible for such medicare
4coverage on or after the effective date of this amendatory Act
5of 1992; or (2) are Medicare-eligible members or dependents of
6a local government unit which began participation in the
7program on or after July 1, 1992; or (3) remain eligible for
8but no longer receive Medicare coverage which they had been
9receiving on or after the effective date of this amendatory Act
10of 1992.
11    Notwithstanding any other provisions of this Act, where a
12covered member or dependents are eligible for benefits under
13the federal Medicare health insurance program (Title XVIII of
14the Social Security Act as added by Public Law 89-97, 89th
15Congress), benefits paid under the State of Illinois program or
16plan will be reduced by the amount of benefits paid by
17Medicare. For members or dependents who are eligible for
18benefits under Social Security or the Railroad Retirement
19system or who had sufficient Medicare-covered government
20employment, benefits shall be reduced by the amount for which
21the member or dependent is eligible under Medicare, except that
22such reduction in benefits shall apply only to those members or
23dependents who (1) first become eligible for such Medicare
24coverage on or after the effective date of this amendatory Act
25of 1992; or (2) are Medicare-eligible members or dependents of
26a local government unit which began participation in the



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1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 100-538, eff. 1-1-18.)
17    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
18    Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.



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1    However, nothing in this Act shall be construed to permit
2the noncontributory portion of any such program to include the
3expenses of obtaining an abortion, induced miscarriage or
4induced premature birth unless, in the opinion of a physician,
5such procedures are necessary for the preservation of the life
6of the woman seeking such treatment, or except an induced
7premature birth intended to produce a live viable child and
8such procedure is necessary for the health of the mother or her
9unborn child.
10(Source: P.A. 100-538, eff. 1-1-18.)
11    Section 10. The Illinois Public Aid Code is amended by
12changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
13    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
14    Sec. 5-5. Medical services. The Illinois Department, by
15rule, shall determine the quantity and quality of and the rate
16of reimbursement for the medical assistance for which payment
17will be authorized, and the medical services to be provided,
18which may include all or part of the following: (1) inpatient
19hospital services; (2) outpatient hospital services; (3) other
20laboratory and X-ray services; (4) skilled nursing home
21services; (5) physicians' services whether furnished in the
22office, the patient's home, a hospital, a skilled nursing home,
23or elsewhere; (6) medical care, or any other type of remedial
24care furnished by licensed practitioners; (7) home health care



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1services; (8) private duty nursing service; (9) clinic
2services; (10) dental services, including prevention and
3treatment of periodontal disease and dental caries disease for
4pregnant women, provided by an individual licensed to practice
5dentistry or dental surgery; for purposes of this item (10),
6"dental services" means diagnostic, preventive, or corrective
7procedures provided by or under the supervision of a dentist in
8the practice of his or her profession; (11) physical therapy
9and related services; (12) prescribed drugs, dentures, and
10prosthetic devices; and eyeglasses prescribed by a physician
11skilled in the diseases of the eye, or by an optometrist,
12whichever the person may select; (13) other diagnostic,
13screening, preventive, and rehabilitative services, including
14to ensure that the individual's need for intervention or
15treatment of mental disorders or substance use disorders or
16co-occurring mental health and substance use disorders is
17determined using a uniform screening, assessment, and
18evaluation process inclusive of criteria, for children and
19adults; for purposes of this item (13), a uniform screening,
20assessment, and evaluation process refers to a process that
21includes an appropriate evaluation and, as warranted, a
22referral; "uniform" does not mean the use of a singular
23instrument, tool, or process that all must utilize; (14)
24transportation and such other expenses as may be necessary;
25(15) medical treatment of sexual assault survivors, as defined
26in Section 1a of the Sexual Assault Survivors Emergency



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1Treatment Act, for injuries sustained as a result of the sexual
2assault, including examinations and laboratory tests to
3discover evidence which may be used in criminal proceedings
4arising from the sexual assault; (16) the diagnosis and
5treatment of sickle cell anemia; and (17) any other medical
6care, and any other type of remedial care recognized under the
7laws of this State, but not including abortions, or induced
8miscarriages or premature births, unless, in the opinion of a
9physician, such procedures are necessary for the preservation
10of the life of the woman seeking such treatment, or except an
11induced premature birth intended to produce a live viable child
12and such procedure is necessary for the health of the mother or
13her unborn child. The Illinois Department, by rule, shall
14prohibit any physician from providing medical assistance to
15anyone eligible therefor under this Code where such physician
16has been found guilty of performing an abortion procedure in a
17wilful and wanton manner upon a woman who was not pregnant at
18the time such abortion procedure was performed. The term "any
19other type of remedial care" shall include nursing care and
20nursing home service for persons who rely on treatment by
21spiritual means alone through prayer for healing.
22    Notwithstanding any other provision of this Section, a
23comprehensive tobacco use cessation program that includes
24purchasing prescription drugs or prescription medical devices
25approved by the Food and Drug Administration shall be covered
26under the medical assistance program under this Article for



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1persons who are otherwise eligible for assistance under this
3    Notwithstanding any other provision of this Code,
4reproductive health care that is otherwise legal in Illinois
5shall be covered under the medical assistance program for
6persons who are otherwise eligible for medical assistance under
7this Article.
8    Notwithstanding any other provision of this Code, the
9Illinois Department may not require, as a condition of payment
10for any laboratory test authorized under this Article, that a
11physician's handwritten signature appear on the laboratory
12test order form. The Illinois Department may, however, impose
13other appropriate requirements regarding laboratory test order
15    Upon receipt of federal approval of an amendment to the
16Illinois Title XIX State Plan for this purpose, the Department
17shall authorize the Chicago Public Schools (CPS) to procure a
18vendor or vendors to manufacture eyeglasses for individuals
19enrolled in a school within the CPS system. CPS shall ensure
20that its vendor or vendors are enrolled as providers in the
21medical assistance program and in any capitated Medicaid
22managed care entity (MCE) serving individuals enrolled in a
23school within the CPS system. Under any contract procured under
24this provision, the vendor or vendors must serve only
25individuals enrolled in a school within the CPS system. Claims
26for services provided by CPS's vendor or vendors to recipients



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



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1supervision of a dentist in the practice of his or her
3    On and after July 1, 2018, targeted dental services, as set
4forth in Exhibit D of the Consent Decree entered by the United
5States District Court for the Northern District of Illinois,
6Eastern Division, in the matter of Memisovski v. Maram, Case
7No. 92 C 1982, that are provided to adults under the medical
8assistance program shall be established at no less than the
9rates set forth in the "New Rate" column in Exhibit D of the
10Consent Decree for targeted dental services that are provided
11to persons under the age of 18 under the medical assistance
13    Notwithstanding any other provision of this Code and
14subject to federal approval, the Department may adopt rules to
15allow a dentist who is volunteering his or her service at no
16cost to render dental services through an enrolled
17not-for-profit health clinic without the dentist personally
18enrolling as a participating provider in the medical assistance
19program. A not-for-profit health clinic shall include a public
20health clinic or Federally Qualified Health Center or other
21enrolled provider, as determined by the Department, through
22which dental services covered under this Section are performed.
23The Department shall establish a process for payment of claims
24for reimbursement for covered dental services rendered under
25this provision.
26    The Illinois Department, by rule, may distinguish and



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1classify the medical services to be provided only in accordance
2with the classes of persons designated in Section 5-2.
3    The Department of Healthcare and Family Services must
4provide coverage and reimbursement for amino acid-based
5elemental formulas, regardless of delivery method, for the
6diagnosis and treatment of (i) eosinophilic disorders and (ii)
7short bowel syndrome when the prescribing physician has issued
8a written order stating that the amino acid-based elemental
9formula is medically necessary.
10    The Illinois Department shall authorize the provision of,
11and shall authorize payment for, screening by low-dose
12mammography for the presence of occult breast cancer for women
1335 years of age or older who are eligible for medical
14assistance under this Article, as follows:
15        (A) A baseline mammogram for women 35 to 39 years of
16    age.
17        (B) An annual mammogram for women 40 years of age or
18    older.
19        (C) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.
24        (D) A comprehensive ultrasound screening and MRI of an
25    entire breast or breasts if a mammogram demonstrates
26    heterogeneous or dense breast tissue or when medically



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



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1an abnormality seen or suspected on a screening mammogram or a
2subjective or objective abnormality otherwise detected in the
4    "Low-dose mammography" means the x-ray examination of the
5breast using equipment dedicated specifically for mammography,
6including the x-ray tube, filter, compression device, and image
7receptor, with an average radiation exposure delivery of less
8than one rad per breast for 2 views of an average size breast.
9The term also includes digital mammography and includes breast
11    "Breast tomosynthesis" means a radiologic procedure that
12involves the acquisition of projection images over the
13stationary breast to produce cross-sectional digital
14three-dimensional images of the breast.
15    If, at any time, the Secretary of the United States
16Department of Health and Human Services, or its successor
17agency, promulgates rules or regulations to be published in the
18Federal Register or publishes a comment in the Federal Register
19or issues an opinion, guidance, or other action that would
20require the State, pursuant to any provision of the Patient
21Protection and Affordable Care Act (Public Law 111-148),
22including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
23successor provision, to defray the cost of any coverage for
24breast tomosynthesis outlined in this paragraph, then the
25requirement that an insurer cover breast tomosynthesis is
26inoperative other than any such coverage authorized under



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1Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
2the State shall not assume any obligation for the cost of
3coverage for breast tomosynthesis set forth in this paragraph.
4    On and after January 1, 2016, the Department shall ensure
5that all networks of care for adult clients of the Department
6include access to at least one breast imaging Center of Imaging
7Excellence as certified by the American College of Radiology.
8    On and after January 1, 2012, providers participating in a
9quality improvement program approved by the Department shall be
10reimbursed for screening and diagnostic mammography at the same
11rate as the Medicare program's rates, including the increased
12reimbursement for digital mammography.
13    The Department shall convene an expert panel including
14representatives of hospitals, free-standing mammography
15facilities, and doctors, including radiologists, to establish
16quality standards for mammography.
17    On and after January 1, 2017, providers participating in a
18breast cancer treatment quality improvement program approved
19by the Department shall be reimbursed for breast cancer
20treatment at a rate that is no lower than 95% of the Medicare
21program's rates for the data elements included in the breast
22cancer treatment quality program.
23    The Department shall convene an expert panel, including
24representatives of hospitals, free-standing breast cancer
25treatment centers, breast cancer quality organizations, and
26doctors, including breast surgeons, reconstructive breast



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



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1cancer. This program shall initially operate as a pilot program
2in areas of the State with the highest incidence of mortality
3related to breast cancer. At least one pilot program site shall
4be in the metropolitan Chicago area and at least one site shall
5be outside the metropolitan Chicago area. On or after July 1,
62016, the pilot program shall be expanded to include one site
7in western Illinois, one site in southern Illinois, one site in
8central Illinois, and 4 sites within metropolitan Chicago. An
9evaluation of the pilot program shall be carried out measuring
10health outcomes and cost of care for those served by the pilot
11program compared to similarly situated patients who are not
12served by the pilot program.
13    The Department shall require all networks of care to
14develop a means either internally or by contract with experts
15in navigation and community outreach to navigate cancer
16patients to comprehensive care in a timely fashion. The
17Department shall require all networks of care to include access
18for patients diagnosed with cancer to at least one academic
19commission on cancer-accredited cancer program as an
20in-network covered benefit.
21    Any medical or health care provider shall immediately
22recommend, to any pregnant woman who is being provided prenatal
23services and is suspected of having a substance use disorder as
24defined in the Substance Use Disorder Act, referral to a local
25substance use disorder treatment program licensed by the
26Department of Human Services or to a licensed hospital which



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



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



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1    providing certain services, which shall be determined by
2    the Illinois Department, to persons in areas covered by the
3    Partnership may receive an additional surcharge for such
4    services.
5        (2) The Department may elect to consider and negotiate
6    financial incentives to encourage the development of
7    Partnerships and the efficient delivery of medical care.
8        (3) Persons receiving medical services through
9    Partnerships may receive medical and case management
10    services above the level usually offered through the
11    medical assistance program.
12    Medical providers shall be required to meet certain
13qualifications to participate in Partnerships to ensure the
14delivery of high quality medical services. These
15qualifications shall be determined by rule of the Illinois
16Department and may be higher than qualifications for
17participation in the medical assistance program. Partnership
18sponsors may prescribe reasonable additional qualifications
19for participation by medical providers, only with the prior
20written approval of the Illinois Department.
21    Nothing in this Section shall limit the free choice of
22practitioners, hospitals, and other providers of medical
23services by clients. In order to ensure patient freedom of
24choice, the Illinois Department shall immediately promulgate
25all rules and take all other necessary actions so that provided
26services may be accessed from therapeutically certified



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1optometrists to the full extent of the Illinois Optometric
2Practice Act of 1987 without discriminating between service
4    The Department shall apply for a waiver from the United
5States Health Care Financing Administration to allow for the
6implementation of Partnerships under this Section.
7    The Illinois Department shall require health care
8providers to maintain records that document the medical care
9and services provided to recipients of Medical Assistance under
10this Article. Such records must be retained for a period of not
11less than 6 years from the date of service or as provided by
12applicable State law, whichever period is longer, except that
13if an audit is initiated within the required retention period
14then the records must be retained until the audit is completed
15and every exception is resolved. The Illinois Department shall
16require health care providers to make available, when
17authorized by the patient, in writing, the medical records in a
18timely fashion to other health care providers who are treating
19or serving persons eligible for Medical Assistance under this
20Article. All dispensers of medical services shall be required
21to maintain and retain business and professional records
22sufficient to fully and accurately document the nature, scope,
23details and receipt of the health care provided to persons
24eligible for medical assistance under this Code, in accordance
25with regulations promulgated by the Illinois Department. The
26rules and regulations shall require that proof of the receipt



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1of prescription drugs, dentures, prosthetic devices and
2eyeglasses by eligible persons under this Section accompany
3each claim for reimbursement submitted by the dispenser of such
4medical services. No such claims for reimbursement shall be
5approved for payment by the Illinois Department without such
6proof of receipt, unless the Illinois Department shall have put
7into effect and shall be operating a system of post-payment
8audit and review which shall, on a sampling basis, be deemed
9adequate by the Illinois Department to assure that such drugs,
10dentures, prosthetic devices and eyeglasses for which payment
11is being made are actually being received by eligible
12recipients. Within 90 days after September 16, 1984 (the
13effective date of Public Act 83-1439), the Illinois Department
14shall establish a current list of acquisition costs for all
15prosthetic devices and any other items recognized as medical
16equipment and supplies reimbursable under this Article and
17shall update such list on a quarterly basis, except that the
18acquisition costs of all prescription drugs shall be updated no
19less frequently than every 30 days as required by Section
21    The rules and regulations of the Illinois Department shall
22require that a written statement including the required opinion
23of a physician shall accompany any claim for reimbursement for
24abortions, or induced miscarriages or premature births. This
25statement shall indicate what procedures were used in providing
26such medical services.



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1    Notwithstanding any other law to the contrary, the Illinois
2Department shall, within 365 days after July 22, 2013 (the
3effective date of Public Act 98-104), establish procedures to
4permit skilled care facilities licensed under the Nursing Home
5Care Act to submit monthly billing claims for reimbursement
6purposes. Following development of these procedures, the
7Department shall, by July 1, 2016, test the viability of the
8new system and implement any necessary operational or
9structural changes to its information technology platforms in
10order to allow for the direct acceptance and payment of nursing
11home claims.
12    Notwithstanding any other law to the contrary, the Illinois
13Department shall, within 365 days after August 15, 2014 (the
14effective date of Public Act 98-963), establish procedures to
15permit ID/DD facilities licensed under the ID/DD Community Care
16Act and MC/DD facilities licensed under the MC/DD Act to submit
17monthly billing claims for reimbursement purposes. Following
18development of these procedures, the Department shall have an
19additional 365 days to test the viability of the new system and
20to ensure that any necessary operational or structural changes
21to its information technology platforms are implemented.
22    The Illinois Department shall require all dispensers of
23medical services, other than an individual practitioner or
24group of practitioners, desiring to participate in the Medical
25Assistance program established under this Article to disclose
26all financial, beneficial, ownership, equity, surety or other



HB4394- 23 -LRB101 16543 KTG 65927 b

1interests in any and all firms, corporations, partnerships,
2associations, business enterprises, joint ventures, agencies,
3institutions or other legal entities providing any form of
4health care services in this State under this Article.
5    The Illinois Department may require that all dispensers of
6medical services desiring to participate in the medical
7assistance program established under this Article disclose,
8under such terms and conditions as the Illinois Department may
9by rule establish, all inquiries from clients and attorneys
10regarding medical bills paid by the Illinois Department, which
11inquiries could indicate potential existence of claims or liens
12for the Illinois Department.
13    Enrollment of a vendor shall be subject to a provisional
14period and shall be conditional for one year. During the period
15of conditional enrollment, the Department may terminate the
16vendor's eligibility to participate in, or may disenroll the
17vendor from, the medical assistance program without cause.
18Unless otherwise specified, such termination of eligibility or
19disenrollment is not subject to the Department's hearing
20process. However, a disenrolled vendor may reapply without
22    The Department has the discretion to limit the conditional
23enrollment period for vendors based upon category of risk of
24the vendor.
25    Prior to enrollment and during the conditional enrollment
26period in the medical assistance program, all vendors shall be



HB4394- 24 -LRB101 16543 KTG 65927 b

1subject to enhanced oversight, screening, and review based on
2the risk of fraud, waste, and abuse that is posed by the
3category of risk of the vendor. The Illinois Department shall
4establish the procedures for oversight, screening, and review,
5which may include, but need not be limited to: criminal and
6financial background checks; fingerprinting; license,
7certification, and authorization verifications; unscheduled or
8unannounced site visits; database checks; prepayment audit
9reviews; audits; payment caps; payment suspensions; and other
10screening as required by federal or State law.
11    The Department shall define or specify the following: (i)
12by provider notice, the "category of risk of the vendor" for
13each type of vendor, which shall take into account the level of
14screening applicable to a particular category of vendor under
15federal law and regulations; (ii) by rule or provider notice,
16the maximum length of the conditional enrollment period for
17each category of risk of the vendor; and (iii) by rule, the
18hearing rights, if any, afforded to a vendor in each category
19of risk of the vendor that is terminated or disenrolled during
20the conditional enrollment period.
21    To be eligible for payment consideration, a vendor's
22payment claim or bill, either as an initial claim or as a
23resubmitted claim following prior rejection, must be received
24by the Illinois Department, or its fiscal intermediary, no
25later than 180 days after the latest date on the claim on which
26medical goods or services were provided, with the following



HB4394- 25 -LRB101 16543 KTG 65927 b

2        (1) In the case of a provider whose enrollment is in
3    process by the Illinois Department, the 180-day period
4    shall not begin until the date on the written notice from
5    the Illinois Department that the provider enrollment is
6    complete.
7        (2) In the case of errors attributable to the Illinois
8    Department or any of its claims processing intermediaries
9    which result in an inability to receive, process, or
10    adjudicate a claim, the 180-day period shall not begin
11    until the provider has been notified of the error.
12        (3) In the case of a provider for whom the Illinois
13    Department initiates the monthly billing process.
14        (4) In the case of a provider operated by a unit of
15    local government with a population exceeding 3,000,000
16    when local government funds finance federal participation
17    for claims payments.
18    For claims for services rendered during a period for which
19a recipient received retroactive eligibility, claims must be
20filed within 180 days after the Department determines the
21applicant is eligible. For claims for which the Illinois
22Department is not the primary payer, claims must be submitted
23to the Illinois Department within 180 days after the final
24adjudication by the primary payer.
25    In the case of long term care facilities, within 45
26calendar days of receipt by the facility of required



HB4394- 26 -LRB101 16543 KTG 65927 b

1prescreening information, new admissions with associated
2admission documents shall be submitted through the Medical
3Electronic Data Interchange (MEDI) or the Recipient
4Eligibility Verification (REV) System or shall be submitted
5directly to the Department of Human Services using required
6admission forms. Effective September 1, 2014, admission
7documents, including all prescreening information, must be
8submitted through MEDI or REV. Confirmation numbers assigned to
9an accepted transaction shall be retained by a facility to
10verify timely submittal. Once an admission transaction has been
11completed, all resubmitted claims following prior rejection
12are subject to receipt no later than 180 days after the
13admission transaction has been completed.
14    Claims that are not submitted and received in compliance
15with the foregoing requirements shall not be eligible for
16payment under the medical assistance program, and the State
17shall have no liability for payment of those claims.
18    To the extent consistent with applicable information and
19privacy, security, and disclosure laws, State and federal
20agencies and departments shall provide the Illinois Department
21access to confidential and other information and data necessary
22to perform eligibility and payment verifications and other
23Illinois Department functions. This includes, but is not
24limited to: information pertaining to licensure;
25certification; earnings; immigration status; citizenship; wage
26reporting; unearned and earned income; pension income;



HB4394- 27 -LRB101 16543 KTG 65927 b

1employment; supplemental security income; social security
2numbers; National Provider Identifier (NPI) numbers; the
3National Practitioner Data Bank (NPDB); program and agency
4exclusions; taxpayer identification numbers; tax delinquency;
5corporate information; and death records.
6    The Illinois Department shall enter into agreements with
7State agencies and departments, and is authorized to enter into
8agreements with federal agencies and departments, under which
9such agencies and departments shall share data necessary for
10medical assistance program integrity functions and oversight.
11The Illinois Department shall develop, in cooperation with
12other State departments and agencies, and in compliance with
13applicable federal laws and regulations, appropriate and
14effective methods to share such data. At a minimum, and to the
15extent necessary to provide data sharing, the Illinois
16Department shall enter into agreements with State agencies and
17departments, and is authorized to enter into agreements with
18federal agencies and departments, including, but not limited
19to: the Secretary of State; the Department of Revenue; the
20Department of Public Health; the Department of Human Services;
21and the Department of Financial and Professional Regulation.
22    Beginning in fiscal year 2013, the Illinois Department
23shall set forth a request for information to identify the
24benefits of a pre-payment, post-adjudication, and post-edit
25claims system with the goals of streamlining claims processing
26and provider reimbursement, reducing the number of pending or



HB4394- 28 -LRB101 16543 KTG 65927 b

1rejected claims, and helping to ensure a more transparent
2adjudication process through the utilization of: (i) provider
3data verification and provider screening technology; and (ii)
4clinical code editing; and (iii) pre-pay, pre- or
5post-adjudicated predictive modeling with an integrated case
6management system with link analysis. Such a request for
7information shall not be considered as a request for proposal
8or as an obligation on the part of the Illinois Department to
9take any action or acquire any products or services.
10    The Illinois Department shall establish policies,
11procedures, standards and criteria by rule for the acquisition,
12repair and replacement of orthotic and prosthetic devices and
13durable medical equipment. Such rules shall provide, but not be
14limited to, the following services: (1) immediate repair or
15replacement of such devices by recipients; and (2) rental,
16lease, purchase or lease-purchase of durable medical equipment
17in a cost-effective manner, taking into consideration the
18recipient's medical prognosis, the extent of the recipient's
19needs, and the requirements and costs for maintaining such
20equipment. Subject to prior approval, such rules shall enable a
21recipient to temporarily acquire and use alternative or
22substitute devices or equipment pending repairs or
23replacements of any device or equipment previously authorized
24for such recipient by the Department. Notwithstanding any
25provision of Section 5-5f to the contrary, the Department may,
26by rule, exempt certain replacement wheelchair parts from prior



HB4394- 29 -LRB101 16543 KTG 65927 b

1approval and, for wheelchairs, wheelchair parts, wheelchair
2accessories, and related seating and positioning items,
3determine the wholesale price by methods other than actual
4acquisition costs.
5    The Department shall require, by rule, all providers of
6durable medical equipment to be accredited by an accreditation
7organization approved by the federal Centers for Medicare and
8Medicaid Services and recognized by the Department in order to
9bill the Department for providing durable medical equipment to
10recipients. No later than 15 months after the effective date of
11the rule adopted pursuant to this paragraph, all providers must
12meet the accreditation requirement.
13    In order to promote environmental responsibility, meet the
14needs of recipients and enrollees, and achieve significant cost
15savings, the Department, or a managed care organization under
16contract with the Department, may provide recipients or managed
17care enrollees who have a prescription or Certificate of
18Medical Necessity access to refurbished durable medical
19equipment under this Section (excluding prosthetic and
20orthotic devices as defined in the Orthotics, Prosthetics, and
21Pedorthics Practice Act and complex rehabilitation technology
22products and associated services) through the State's
23assistive technology program's reutilization program, using
24staff with the Assistive Technology Professional (ATP)
25Certification if the refurbished durable medical equipment:
26(i) is available; (ii) is less expensive, including shipping



HB4394- 30 -LRB101 16543 KTG 65927 b

1costs, than new durable medical equipment of the same type;
2(iii) is able to withstand at least 3 years of use; (iv) is
3cleaned, disinfected, sterilized, and safe in accordance with
4federal Food and Drug Administration regulations and guidance
5governing the reprocessing of medical devices in health care
6settings; and (v) equally meets the needs of the recipient or
7enrollee. The reutilization program shall confirm that the
8recipient or enrollee is not already in receipt of same or
9similar equipment from another service provider, and that the
10refurbished durable medical equipment equally meets the needs
11of the recipient or enrollee. Nothing in this paragraph shall
12be construed to limit recipient or enrollee choice to obtain
13new durable medical equipment or place any additional prior
14authorization conditions on enrollees of managed care
16    The Department shall execute, relative to the nursing home
17prescreening project, written inter-agency agreements with the
18Department of Human Services and the Department on Aging, to
19effect the following: (i) intake procedures and common
20eligibility criteria for those persons who are receiving
21non-institutional services; and (ii) the establishment and
22development of non-institutional services in areas of the State
23where they are not currently available or are undeveloped; and
24(iii) notwithstanding any other provision of law, subject to
25federal approval, on and after July 1, 2012, an increase in the
26determination of need (DON) scores from 29 to 37 for applicants



HB4394- 31 -LRB101 16543 KTG 65927 b

1for institutional and home and community-based long term care;
2if and only if federal approval is not granted, the Department
3may, in conjunction with other affected agencies, implement
4utilization controls or changes in benefit packages to
5effectuate a similar savings amount for this population; and
6(iv) no later than July 1, 2013, minimum level of care
7eligibility criteria for institutional and home and
8community-based long term care; and (v) no later than October
91, 2013, establish procedures to permit long term care
10providers access to eligibility scores for individuals with an
11admission date who are seeking or receiving services from the
12long term care provider. In order to select the minimum level
13of care eligibility criteria, the Governor shall establish a
14workgroup that includes affected agency representatives and
15stakeholders representing the institutional and home and
16community-based long term care interests. This Section shall
17not restrict the Department from implementing lower level of
18care eligibility criteria for community-based services in
19circumstances where federal approval has been granted.
20    The Illinois Department shall develop and operate, in
21cooperation with other State Departments and agencies and in
22compliance with applicable federal laws and regulations,
23appropriate and effective systems of health care evaluation and
24programs for monitoring of utilization of health care services
25and facilities, as it affects persons eligible for medical
26assistance under this Code.



HB4394- 32 -LRB101 16543 KTG 65927 b

1    The Illinois Department shall report annually to the
2General Assembly, no later than the second Friday in April of
31979 and each year thereafter, in regard to:
4        (a) actual statistics and trends in utilization of
5    medical services by public aid recipients;
6        (b) actual statistics and trends in the provision of
7    the various medical services by medical vendors;
8        (c) current rate structures and proposed changes in
9    those rate structures for the various medical vendors; and
10        (d) efforts at utilization review and control by the
11    Illinois Department.
12    The period covered by each report shall be the 3 years
13ending on the June 30 prior to the report. The report shall
14include suggested legislation for consideration by the General
15Assembly. The requirement for reporting to the General Assembly
16shall be satisfied by filing copies of the report as required
17by Section 3.1 of the General Assembly Organization Act, and
18filing such additional copies with the State Government Report
19Distribution Center for the General Assembly as is required
20under paragraph (t) of Section 7 of the State Library Act.
21    Rulemaking authority to implement Public Act 95-1045, if
22any, is conditioned on the rules being adopted in accordance
23with all provisions of the Illinois Administrative Procedure
24Act and all rules and procedures of the Joint Committee on
25Administrative Rules; any purported rule not so adopted, for
26whatever reason, is unauthorized.



HB4394- 33 -LRB101 16543 KTG 65927 b

1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate of
4reimbursement for services or other payments in accordance with
5Section 5-5e.
6    Because kidney transplantation can be an appropriate,
7cost-effective alternative to renal dialysis when medically
8necessary and notwithstanding the provisions of Section 1-11 of
9this Code, beginning October 1, 2014, the Department shall
10cover kidney transplantation for noncitizens with end-stage
11renal disease who are not eligible for comprehensive medical
12benefits, who meet the residency requirements of Section 5-3 of
13this Code, and who would otherwise meet the financial
14requirements of the appropriate class of eligible persons under
15Section 5-2 of this Code. To qualify for coverage of kidney
16transplantation, such person must be receiving emergency renal
17dialysis services covered by the Department. Providers under
18this Section shall be prior approved and certified by the
19Department to perform kidney transplantation and the services
20under this Section shall be limited to services associated with
21kidney transplantation.
22    Notwithstanding any other provision of this Code to the
23contrary, on or after July 1, 2015, all FDA approved forms of
24medication assisted treatment prescribed for the treatment of
25alcohol dependence or treatment of opioid dependence shall be
26covered under both fee for service and managed care medical



HB4394- 34 -LRB101 16543 KTG 65927 b

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



HB4394- 35 -LRB101 16543 KTG 65927 b

1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5    A federally qualified health center, as defined in Section
61905(l)(2)(B) of the federal Social Security Act, shall be
7reimbursed by the Department in accordance with the federally
8qualified health center's encounter rate for services provided
9to medical assistance recipients that are performed by a dental
10hygienist, as defined under the Illinois Dental Practice Act,
11working under the general supervision of a dentist and employed
12by a federally qualified health center.
13(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
14100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
156-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
16eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
17100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
181-1-20; revised 9-18-19.)
19    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
20    Sec. 5-8. Practitioners. In supplying medical assistance,
21the Illinois Department may provide for the legally authorized
22services of (i) persons licensed under the Medical Practice Act
23of 1987, as amended, except as hereafter in this Section
24stated, whether under a general or limited license, (ii)
25persons licensed under the Nurse Practice Act as advanced



HB4394- 36 -LRB101 16543 KTG 65927 b

1practice registered nurses, regardless of whether or not the
2persons have written collaborative agreements, (iii) persons
3licensed or registered under other laws of this State to
4provide dental, medical, pharmaceutical, optometric,
5podiatric, or nursing services, or other remedial care
6recognized under State law, (iv) persons licensed under other
7laws of this State as a clinical social worker, and (v) persons
8licensed under other laws of this State as physician
9assistants. The Department shall adopt rules, no later than 90
10days after January 1, 2017 (the effective date of Public Act
1199-621), for the legally authorized services of persons
12licensed under other laws of this State as a clinical social
13worker. The Department may not provide for legally authorized
14services of any physician who has been convicted of having
15performed an abortion procedure in a wilful and wanton manner
16on a woman who was not pregnant at the time such abortion
17procedure was performed. The utilization of the services of
18persons engaged in the treatment or care of the sick, which
19persons are not required to be licensed or registered under the
20laws of this State, is not prohibited by this Section.
21(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
22100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff.
231-1-18; 100-863, eff. 8-14-18.)
24    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
25    Sec. 5-9. Choice of medical dispensers. Applicants and



HB4394- 37 -LRB101 16543 KTG 65927 b

1recipients shall be entitled to free choice of those qualified
2practitioners, hospitals, nursing homes, and other dispensers
3of medical services meeting the requirements and complying with
4the rules and regulations of the Illinois Department. However,
5the Director of Healthcare and Family Services may, after
6providing reasonable notice and opportunity for hearing, deny,
7suspend or terminate any otherwise qualified person, firm,
8corporation, association, agency, institution, or other legal
9entity, from participation as a vendor of goods or services
10under the medical assistance program authorized by this Article
11if the Director finds such vendor of medical services in
12violation of this Act or the policy or rules and regulations
13issued pursuant to this Act. Any physician who has been
14convicted of performing an abortion procedure in a wilful and
15wanton manner upon a woman who was not pregnant at the time
16such abortion procedure was performed shall be automatically
17removed from the list of physicians qualified to participate as
18a vendor of medical services under the medical assistance
19program authorized by this Article.
20(Source: P.A. 100-538, eff. 1-1-18.)
21    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
22    Sec. 6-1. Eligibility requirements. Financial aid in
23meeting basic maintenance requirements shall be given under
24this Article to or in behalf of persons who meet the
25eligibility conditions of Sections 6-1.1 through 6-1.10. In



HB4394- 38 -LRB101 16543 KTG 65927 b

1addition, each unit of local government subject to this Article
2shall provide persons receiving financial aid in meeting basic
3maintenance requirements with financial aid for either (a)
4necessary treatment, care, and supplies required because of
5illness or disability, or (b) acute medical treatment, care,
6and supplies only. If a local governmental unit elects to
7provide financial aid for acute medical treatment, care, and
8supplies only, the general types of acute medical treatment,
9care, and supplies for which financial aid is provided shall be
10specified in the general assistance rules of the local
11governmental unit, which rules shall provide that financial aid
12is provided, at a minimum, for acute medical treatment, care,
13or supplies necessitated by a medical condition for which prior
14approval or authorization of medical treatment, care, or
15supplies is not required by the general assistance rules of the
16Illinois Department. Nothing in this Article shall be construed
17to permit the granting of financial aid where the purpose of
18such aid is to obtain an abortion, induced miscarriage or
19induced premature birth unless, in the opinion of a physician,
20such procedures are necessary for the preservation of the life
21of the woman seeking such treatment, or except an induced
22premature birth intended to produce a live viable child and
23such procedure is necessary for the health of the mother or her
24unborn child.
25(Source: P.A. 100-538, eff. 1-1-18.)



HB4394- 39 -LRB101 16543 KTG 65927 b

1    Section 15. The Problem Pregnancy Health Services and Care
2Act is amended by changing Section 4-100 as follows:
3    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
4    Sec. 4-100. The Department may make grants to nonprofit
5agencies and organizations which do not use such grants to
6refer or counsel for, or perform, abortions and which
7coordinate and establish linkages among services that will
8further the purposes of this Act and, where appropriate, will
9provide, supplement, or improve the quality of such services.
10(Source: P.A. 100-538, eff. 1-1-18.)