Illinois General Assembly - Full Text of SB0048
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Full Text of SB0048  103rd General Assembly




State of Illinois
2023 and 2024


Introduced 1/20/2023, by Sen. Dave Syverson


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning vendor enrollment in the medical assistance program, provides that nothing in the provision shall be construed to require a vendor or provider who exclusively offers telehealth services or any telehealth provider group to maintain a physical address or office in Illinois or have an Illinois mailing address in order to be eligible to enroll as a vendor or provider in the medical assistance program, if the vendor, provider, or telehealth provider group is licensed or authorized to practice in Illinois and has a principal place of business located in the United States.

LRB103 05006 KTG 50018 b





SB0048LRB103 05006 KTG 50018 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant individuals, provided by an individual licensed
22to practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or



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



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1Act of 1987 and acting within the scope of his or her license,
2including, but not limited to, chiropractic manipulative
3treatment; and (17) any other medical care, and any other type
4of remedial care recognized under the laws of this State. The
5term "any other type of remedial care" shall include nursing
6care and nursing home service for persons who rely on
7treatment by spiritual means alone through prayer for healing.
8    Notwithstanding any other provision of this Section, a
9comprehensive tobacco use cessation program that includes
10purchasing prescription drugs or prescription medical devices
11approved by the Food and Drug Administration shall be covered
12under the medical assistance program under this Article for
13persons who are otherwise eligible for assistance under this
15    Notwithstanding any other provision of this Code,
16reproductive health care that is otherwise legal in Illinois
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance
19under this Article.
20    Notwithstanding any other provision of this Section, all
21tobacco cessation medications approved by the United States
22Food and Drug Administration and all individual and group
23tobacco cessation counseling services and telephone-based
24counseling services and tobacco cessation medications provided
25through the Illinois Tobacco Quitline shall be covered under
26the medical assistance program for persons who are otherwise



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1eligible for assistance under this Article. The Department
2shall comply with all federal requirements necessary to obtain
3federal financial participation, as specified in 42 CFR
4433.15(b)(7), for telephone-based counseling services provided
5through the Illinois Tobacco Quitline, including, but not
6limited to: (i) entering into a memorandum of understanding or
7interagency agreement with the Department of Public Health, as
8administrator of the Illinois Tobacco Quitline; and (ii)
9developing a cost allocation plan for Medicaid-allowable
10Illinois Tobacco Quitline services in accordance with 45 CFR
1195.507. The Department shall submit the memorandum of
12understanding or interagency agreement, the cost allocation
13plan, and all other necessary documentation to the Centers for
14Medicare and Medicaid Services for review and approval.
15Coverage under this paragraph shall be contingent upon federal
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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



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



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1enrolling as a participating provider in the medical
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
9    On and after January 1, 2022, the Department of Healthcare
10and Family Services shall administer and regulate a
11school-based dental program that allows for the out-of-office
12delivery of preventative dental services in a school setting
13to children under 19 years of age. The Department shall
14establish, by rule, guidelines for participation by providers
15and set requirements for follow-up referral care based on the
16requirements established in the Dental Office Reference Manual
17published by the Department that establishes the requirements
18for dentists participating in the All Kids Dental School
19Program. Every effort shall be made by the Department when
20developing the program requirements to consider the different
21geographic differences of both urban and rural areas of the
22State for initial treatment and necessary follow-up care. No
23provider shall be charged a fee by any unit of local government
24to participate in the school-based dental program administered
25by the Department. Nothing in this paragraph shall be
26construed to limit or preempt a home rule unit's or school



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



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1    provider for individuals under 40 years of age and having
2    a family history of breast cancer, prior personal history
3    of breast cancer, positive genetic testing, or other risk
4    factors.
5        (D) A comprehensive ultrasound screening and MRI of an
6    entire breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue or when medically
8    necessary as determined by a physician licensed to
9    practice medicine in all of its branches.
10        (E) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13        (F) A diagnostic mammogram when medically necessary,
14    as determined by a physician licensed to practice medicine
15    in all its branches, advanced practice registered nurse,
16    or physician assistant.
17    The Department shall not impose a deductible, coinsurance,
18copayment, or any other cost-sharing requirement on the
19coverage provided under this paragraph; except that this
20sentence does not apply to coverage of diagnostic mammograms
21to the extent such coverage would disqualify a high-deductible
22health plan from eligibility for a health savings account
23pursuant to Section 223 of the Internal Revenue Code (26
24U.S.C. 223).
25    All screenings shall include a physical breast exam,
26instruction on self-examination and information regarding the



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1frequency of self-examination and its value as a preventative
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
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 and
17includes breast tomosynthesis.
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



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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
6paragraph, 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 paragraph.
12    On and after January 1, 2016, the Department shall ensure
13that all networks of care for adult clients of the Department
14include access to at least one breast imaging Center of
15Imaging Excellence as certified by the American College of
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall
19be reimbursed for screening and diagnostic mammography at the
20same rate as the Medicare program's rates, including the
21increased reimbursement for digital mammography and, after
22January 1, 2023 (the effective date of Public Act 102-1018)
23this amendatory Act of the 102nd General Assembly, breast
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography



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1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free-standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23individuals who are age-appropriate for screening mammography,
24but who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening
26mammography. The Department shall work with experts in breast



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



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1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include
4access for patients diagnosed with cancer to at least one
5academic commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    The Department shall provide coverage and reimbursement
8for a human papillomavirus (HPV) vaccine that is approved for
9marketing by the federal Food and Drug Administration for all
10persons between the ages of 9 and 45 and persons of the age of
1146 and above who have been diagnosed with cervical dysplasia
12with a high risk of recurrence or progression. The Department
13shall disallow any preauthorization requirements for the
14administration of the human papillomavirus (HPV) vaccine.
15    On or after July 1, 2022, individuals who are otherwise
16eligible for medical assistance under this Article shall
17receive coverage for perinatal depression screenings for the
1812-month period beginning on the last day of their pregnancy.
19Medical assistance coverage under this paragraph shall be
20conditioned on the use of a screening instrument approved by
21the Department.
22    Any medical or health care provider shall immediately
23recommend, to any pregnant individual who is being provided
24prenatal services and is suspected of having a substance use
25disorder as defined in the Substance Use Disorder Act,
26referral to a local substance use disorder treatment program



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



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



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1medical services delivered by Partnership providers to clients
2in target areas according to provisions of this Article and
3the Illinois Health Finance Reform Act, except that:
4        (1) Physicians participating in a Partnership and
5    providing certain services, which shall be determined by
6    the Illinois Department, to persons in areas covered by
7    the Partnership may receive an additional surcharge for
8    such services.
9        (2) The Department may elect to consider and negotiate
10    financial incentives to encourage the development of
11    Partnerships and the efficient delivery of medical care.
12        (3) Persons receiving medical services through
13    Partnerships may receive medical and case management
14    services above the level usually offered through the
15    medical assistance program.
16    Medical providers shall be required to meet certain
17qualifications to participate in Partnerships to ensure the
18delivery of high quality medical services. These
19qualifications shall be determined by rule of the Illinois
20Department and may be higher than qualifications for
21participation in the medical assistance program. Partnership
22sponsors may prescribe reasonable additional qualifications
23for participation by medical providers, only with the prior
24written approval of the Illinois Department.
25    Nothing in this Section shall limit the free choice of
26practitioners, hospitals, and other providers of medical



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1services by clients. In order to ensure patient freedom of
2choice, the Illinois Department shall immediately promulgate
3all rules and take all other necessary actions so that
4provided services may be accessed from therapeutically
5certified optometrists to the full extent of the Illinois
6Optometric Practice Act of 1987 without discriminating between
7service providers.
8    The Department shall apply for a waiver from the United
9States Health Care Financing Administration to allow for the
10implementation of Partnerships under this Section.
11    The Illinois Department shall require health care
12providers to maintain records that document the medical care
13and services provided to recipients of Medical Assistance
14under this Article. Such records must be retained for a period
15of not less than 6 years from the date of service or as
16provided by applicable State law, whichever period is longer,
17except that if an audit is initiated within the required
18retention period then the records must be retained until the
19audit is completed and every exception is resolved. The
20Illinois Department shall require health care providers to
21make available, when authorized by the patient, in writing,
22the medical records in a timely fashion to other health care
23providers who are treating or serving persons eligible for
24Medical Assistance under this Article. All dispensers of
25medical services shall be required to maintain and retain
26business and professional records sufficient to fully and



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1accurately document the nature, scope, details and receipt of
2the health care provided to persons eligible for medical
3assistance under this Code, in accordance with regulations
4promulgated by the Illinois Department. The rules and
5regulations shall require that proof of the receipt of
6prescription drugs, dentures, prosthetic devices and
7eyeglasses by eligible persons under this Section accompany
8each claim for reimbursement submitted by the dispenser of
9such medical services. No such claims for reimbursement shall
10be approved for payment by the Illinois Department without
11such proof of receipt, unless the Illinois Department shall
12have put into effect and shall be operating a system of
13post-payment audit and review which shall, on a sampling
14basis, be deemed adequate by the Illinois Department to assure
15that such drugs, dentures, prosthetic devices and eyeglasses
16for which payment is being made are actually being received by
17eligible recipients. Within 90 days after September 16, 1984
18(the effective date of Public Act 83-1439), the Illinois
19Department shall establish a current list of acquisition costs
20for all prosthetic devices and any other items recognized as
21medical equipment and supplies reimbursable under this Article
22and shall update such list on a quarterly basis, except that
23the acquisition costs of all prescription drugs shall be
24updated no less frequently than every 30 days as required by
25Section 5-5.12.
26    Notwithstanding any other law to the contrary, the



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1Illinois Department shall, within 365 days after July 22, 2013
2(the effective date of Public Act 98-104), establish
3procedures to permit skilled care facilities licensed under
4the Nursing Home Care Act to submit monthly billing claims for
5reimbursement purposes. Following development of these
6procedures, the Department shall, by July 1, 2016, test the
7viability of the new system and implement any necessary
8operational or structural changes to its information
9technology platforms in order to allow for the direct
10acceptance and payment of nursing home claims.
11    Notwithstanding any other law to the contrary, the
12Illinois Department shall, within 365 days after August 15,
132014 (the effective date of Public Act 98-963), establish
14procedures to permit ID/DD facilities licensed under the ID/DD
15Community Care Act and MC/DD facilities licensed under the
16MC/DD Act to submit monthly billing claims for reimbursement
17purposes. Following development of these procedures, the
18Department shall have an additional 365 days to test the
19viability of the new system and to ensure that any necessary
20operational or structural changes to its information
21technology 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



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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
12liens for the Illinois Department.
13    Enrollment of a vendor shall be subject to a provisional
14period and shall be conditional for one year. During the
15period of conditional enrollment, the Department may terminate
16the vendor's eligibility to participate in, or may disenroll
17the vendor 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 and



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1providers shall be subject to enhanced oversight, screening,
2and review based on the risk of fraud, waste, and abuse that is
3posed by the category of risk of the vendor or provider. The
4Illinois Department shall establish the procedures for
5oversight, screening, and review, which may include, but need
6not be limited to: criminal and financial background checks;
7fingerprinting; license, certification, and authorization
8verifications; unscheduled or unannounced site visits if the
9vendor or provider offers in-person services; database checks;
10prepayment audit reviews; audits; payment caps; payment
11suspensions; and other screening as required by federal or
12State law. However, nothing in this Section shall be construed
13to require any vendor or provider who exclusively offers
14telehealth services or any telehealth provider group to
15maintain a physical address or office in Illinois or have an
16Illinois mailing address in order to be eligible to enroll as a
17vendor or provider in the medical assistance program, if the
18vendor, provider, or telehealth provider group is licensed or
19authorized to practice in Illinois and has a principal place
20of business located in the United States.
21    The Department shall define or specify the following: (i)
22by provider notice, the "category of risk of the vendor" for
23each type of vendor, which shall take into account the level of
24screening applicable to a particular category of vendor under
25federal law and regulations; (ii) by rule or provider notice,
26the maximum length of the conditional enrollment period for



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



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



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1shall have no liability for payment of those claims.
2    To the extent consistent with applicable information and
3privacy, security, and disclosure laws, State and federal
4agencies and departments shall provide the Illinois Department
5access to confidential and other information and data
6necessary to perform eligibility and payment verifications and
7other Illinois Department functions. This includes, but is not
8limited to: information pertaining to licensure;
9certification; earnings; immigration status; citizenship; wage
10reporting; unearned and earned income; pension income;
11employment; supplemental security income; social security
12numbers; National Provider Identifier (NPI) numbers; the
13National Practitioner Data Bank (NPDB); program and agency
14exclusions; taxpayer identification numbers; tax delinquency;
15corporate information; and death records.
16    The Illinois Department shall enter into agreements with
17State agencies and departments, and is authorized to enter
18into agreements with federal agencies and departments, under
19which such agencies and departments shall share data necessary
20for medical assistance program integrity functions and
21oversight. The Illinois Department shall develop, in
22cooperation with other State departments and agencies, and in
23compliance with applicable federal laws and regulations,
24appropriate and effective methods to share such data. At a
25minimum, and to the extent necessary to provide data sharing,
26the Illinois Department shall enter into agreements with State



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



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



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



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1    The Department shall execute, relative to the nursing home
2prescreening project, written inter-agency agreements with the
3Department of Human Services and the Department on Aging, to
4effect the following: (i) intake procedures and common
5eligibility criteria for those persons who are receiving
6non-institutional services; and (ii) the establishment and
7development of non-institutional services in areas of the
8State where they are not currently available or are
9undeveloped; and (iii) notwithstanding any other provision of
10law, subject to federal approval, on and after July 1, 2012, an
11increase in the determination of need (DON) scores from 29 to
1237 for applicants for institutional and home and
13community-based long term care; if and only if federal
14approval is not granted, the Department may, in conjunction
15with other affected agencies, implement utilization controls
16or changes in benefit packages to effectuate a similar savings
17amount for this population; and (iv) no later than July 1,
182013, minimum level of care eligibility criteria for
19institutional and home and community-based long term care; and
20(v) no later than October 1, 2013, establish procedures to
21permit long term care providers access to eligibility scores
22for individuals with an admission date who are seeking or
23receiving services from the long term care provider. In order
24to select the minimum level of care eligibility criteria, the
25Governor shall establish a workgroup that includes affected
26agency representatives and stakeholders representing the



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1institutional and home and community-based long term care
2interests. This Section shall not restrict the Department from
3implementing lower level of care eligibility criteria for
4community-based services in circumstances where federal
5approval has been granted.
6    The Illinois Department shall develop and operate, in
7cooperation with other State Departments and agencies and in
8compliance with applicable federal laws and regulations,
9appropriate and effective systems of health care evaluation
10and programs for monitoring of utilization of health care
11services and facilities, as it affects persons eligible for
12medical assistance under this Code.
13    The Illinois Department shall report annually to the
14General Assembly, no later than the second Friday in April of
151979 and each year thereafter, in regard to:
16        (a) actual statistics and trends in utilization of
17    medical services by public aid recipients;
18        (b) actual statistics and trends in the provision of
19    the various medical services by medical vendors;
20        (c) current rate structures and proposed changes in
21    those rate structures for the various medical vendors; and
22        (d) efforts at utilization review and control by the
23    Illinois Department.
24    The period covered by each report shall be the 3 years
25ending on the June 30 prior to the report. The report shall
26include suggested legislation for consideration by the General



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1Assembly. The requirement for reporting to the General
2Assembly shall be satisfied by filing copies of the report as
3required by Section 3.1 of the General Assembly Organization
4Act, and filing such additional copies with the State
5Government Report Distribution Center for the General Assembly
6as is required under paragraph (t) of Section 7 of the State
7Library Act.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14    On and after July 1, 2012, the Department shall reduce any
15rate of reimbursement for services or other payments or alter
16any methodologies authorized by this Code to reduce any rate
17of reimbursement for services or other payments in accordance
18with Section 5-5e.
19    Because kidney transplantation can be an appropriate,
20cost-effective alternative to renal dialysis when medically
21necessary and notwithstanding the provisions of Section 1-11
22of this Code, beginning October 1, 2014, the Department shall
23cover kidney transplantation for noncitizens with end-stage
24renal disease who are not eligible for comprehensive medical
25benefits, who meet the residency requirements of Section 5-3
26of this Code, and who would otherwise meet the financial



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



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1As used in this Section, "opioid antagonist" means a drug that
2binds to opioid receptors and blocks or inhibits the effect of
3opioids acting on those receptors, including, but not limited
4to, naloxone hydrochloride or any other similarly acting drug
5approved by the U.S. Food and Drug Administration. The
6Department shall not impose a copayment on the coverage
7provided for naloxone hydrochloride under the medical
8assistance program.
9    Upon federal approval, the Department shall provide
10coverage and reimbursement for all drugs that are approved for
11marketing by the federal Food and Drug Administration and that
12are recommended by the federal Public Health Service or the
13United States Centers for Disease Control and Prevention for
14pre-exposure prophylaxis and related pre-exposure prophylaxis
15services, including, but not limited to, HIV and sexually
16transmitted infection screening, treatment for sexually
17transmitted infections, medical monitoring, assorted labs, and
18counseling to reduce the likelihood of HIV infection among
19individuals who are not infected with HIV but who are at high
20risk of HIV infection.
21    A federally qualified health center, as defined in Section
221905(l)(2)(B) of the federal Social Security Act, shall be
23reimbursed by the Department in accordance with the federally
24qualified health center's encounter rate for services provided
25to medical assistance recipients that are performed by a
26dental hygienist, as defined under the Illinois Dental



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1Practice Act, working under the general supervision of a
2dentist and employed by a federally qualified health center.
3    Within 90 days after October 8, 2021 (the effective date
4of Public Act 102-665), the Department shall seek federal
5approval of a State Plan amendment to expand coverage for
6family planning services that includes presumptive eligibility
7to individuals whose income is at or below 208% of the federal
8poverty level. Coverage under this Section shall be effective
9beginning no later than December 1, 2022.
10    Subject to approval by the federal Centers for Medicare
11and Medicaid Services of a Title XIX State Plan amendment
12electing the Program of All-Inclusive Care for the Elderly
13(PACE) as a State Medicaid option, as provided for by Subtitle
14I (commencing with Section 4801) of Title IV of the Balanced
15Budget Act of 1997 (Public Law 105-33) and Part 460
16(commencing with Section 460.2) of Subchapter E of Title 42 of
17the Code of Federal Regulations, PACE program services shall
18become a covered benefit of the medical assistance program,
19subject to criteria established in accordance with all
20applicable laws.
21    Notwithstanding any other provision of this Code,
22community-based pediatric palliative care from a trained
23interdisciplinary team shall be covered under the medical
24assistance program as provided in Section 15 of the Pediatric
25Palliative Care Act.
26    Notwithstanding any other provision of this Code, within



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112 months after June 2, 2022 (the effective date of Public Act
2102-1037) this amendatory Act of the 102nd General Assembly
3and subject to federal approval, acupuncture services
4performed by an acupuncturist licensed under the Acupuncture
5Practice Act who is acting within the scope of his or her
6license shall be covered under the medical assistance program.
7The Department shall apply for any federal waiver or State
8Plan amendment, if required, to implement this paragraph. The
9Department may adopt any rules, including standards and
10criteria, necessary to implement this paragraph.
11(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
12102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1335, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1455-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
15102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
161-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
17102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
181-1-23; revised 12-14-22.)